Today’s children and adolescents are immersed in both traditional and new forms of digital media. Research on traditional media, such as television, has identified health concerns and negative outcomes that correlate with the duration and content of viewing. Over the past decade, the use of digital media, including interactive and social media, has grown, and research evidence suggests that these newer media offer both benefits and risks to the health of children and teenagers. Evidence-based benefits identified from the use of digital and social media include early learning, exposure to new ideas and knowledge, increased opportunities for social contact and support, and new opportunities to access health promotion messages and information. Risks of such media include negative health effects on sleep, attention, and learning; a higher incidence of obesity and depression; exposure to inaccurate, inappropriate, or unsafe content and contacts; and compromised privacy and confidentiality. This technical report reviews the literature regarding these opportunities and risks, framed around clinical questions, for children from birth to adulthood. To promote health and wellness in children and adolescents, it is important to maintain adequate physical activity, healthy nutrition, good sleep hygiene, and a nurturing social environment. A healthy Family Media Use Plan (www.healthychildren.org/MediaUsePlan) that is individualized for a specific child, teenager, or family can identify an appropriate balance between screen time/online time and other activities, set boundaries for accessing content, guide displays of personal information, encourage age-appropriate critical thinking and digital literacy, and support open family communication and implementation of consistent rules about media use.

Introduction

Today’s generation of children and adolescents are growing up immersed in media, including broadcast and social media. Broadcast media include television and movies. Interactive media include social media and video games in which users can both consume and create content. Interactive media allow information sharing and provide an engaging digital environment that becomes highly personalized.

Media Use Patterns

The most common broadcast medium continues to be TV. A recent study found that TV hours among school-aged children have decreased in the past decade for children younger than 8 years.1 However, among children aged 8 years and older, average daily TV time remains over 2 hours per day.2 TV viewing also has changed over the past decade, with content available via streaming or social media sites, such as YouTube and Netflix.

Overall media use among adolescents has continued to grow over the past decade, aided by the recent increase in mobile phone use among teenagers. Approximately three-quarters of teenagers today own a smartphone,3 which allows access to the Internet, streaming TV/videos, and interactive “apps.” Approximately one-quarter of teenagers describe themselves as “constantly connected” to the Internet.

Social media sites and mobile apps provide platforms for users to create an online identity, communicate with others, and build social networks. At present, 76% of teenagers use at least 1 social media site. Although Facebook remains the most popular social media site,3 teenagers do not typically commit to just 1 social media platform; more than 70% maintain a “social media portfolio” of several selected sites, including Facebook, Twitter, and Instagram.3 Mobile apps provide a breadth of functions, such as photo sharing, games, and video-chatting.

Video games remain very popular among families; 4 of 5 households own a device used to play video games.Boys are the most avid video game players, with 91% of boys reporting having access to a game console and 84% reporting playing video games online or on a cell phone.

Benefits of Media

Both traditional and social media can provide exposure to new ideas and information, raising awareness of current events and issues. Interactive media also can provide opportunities for the promotion of community participation and civic engagement. Students can collaborate with others on assignments and projects on many online media platforms. The use of social media helps families and friends who are separated geographically communicate across the miles.

Social media can enhance access to valuable support networks, which may be particularly helpful for patients with ongoing illnesses, conditions, or disabilities.In 1 study, young adults described the benefits of seeking health information online and through social media, and recognized these channels as useful supplementary sources of information to health care visits.6 Research also supports the use of social media to foster social inclusion among users who may feel excluded or who are seeking a welcoming community: for example, those identifying as lesbian, gay, bisexual, transgender, questioning, or intersex. Finally, social media may be used to enhance wellness and promote healthy behaviors, such as smoking cessation and balanced nutrition.

Risks of Media

A first area of health concern is media use and obesity, and most studies have focused on TV. One study found that the odds of being overweight were almost 5 times greater for adolescents who watch more than 5 hours of TV per day compared with those who watch 0 to 2 hours.9 This study’s findings contributed to recommendations by the American Academy of Pediatrics that children have 2 hours or less of sedentary screen time daily. More recent studies have provided new evidence that watching TV for more than 1.5 hours daily was a risk factor for obesity, but only for children 4 through 9 years of age.10 Increased caloric intake via snacking while watching TV has been shown to be a risk factor for obesity, as is exposure to advertising for high-calorie foods and snacks.Having a TV in the bedroom continues to be associated with the risk of obesity.

Evidence suggests that media use can negatively affect sleep.Studies show that those with higher social media use15 or who sleep with mobile devices in their roomswere at greater risk of sleep disturbances. Exposure to light (particularly blue light) and activity from screens before bed affects melatonin levels and can delay or disrupt sleep.Media use around or after bedtime can disrupt sleep and negatively affect school performance.

Children who overuse online media are at risk of problematic Internet use, and heavy users of video games are at risk of Internet gaming disorder. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition,lists both as conditions in need of further research. Symptoms can include a preoccupation with the activity, decreased interest in offline or “real life” relationships, unsuccessful attempts to decrease use, and withdrawal symptoms. The prevalence of problematic Internet use among children and adolescents is between 4% and 8%,21,22 and up to 8.5% of US youth 8 to 18 years of age meet criteria for Internet gaming disorder.

At home, many children and teenagers use entertainment media at the same time that they are engaged in other tasks, such as homework.A growing body of evidence suggests that the use of media while engaged in academic tasks has negative consequences on learning.

Media Influence

Evidence gathered over decades supports links between media exposure and health behaviors among teenagers.The exposure of adolescents through media to alcohol,28,29 tobacco use,30,31 or sexual behaviors is associated with earlier initiation of these behaviors.

Adolescents’ displays on social media frequently include portrayal of health risk behaviors, such as substance use, sexual behaviors, self-injury, or disordered eating.Peer viewers of such content may see these behaviors as normative and desirable.Research from both the United States and the United Kingdom indicates that the major alcohol brands maintain a strong presence on Facebook, Twitter, and YouTube.

Cyberbullying, Sexting, and Online Solicitation

Cyberbullying and traditional bullying overlap, although online bullying presents unique challenges. These challenges include that perpetrators can be anonymous and bully at any time of day, that information can spread online rapidly, and that perpetrator and target roles can be quite fluid in the online world. Cyberbullying can lead to short- and long-term negative social, academic, and health consequences for both the perpetrator and the target. Fortunately, newer studies suggest that interventions that target bullying may reduce cyberbullying.

“Sexting” is commonly defined as the electronic transmission of nude or seminude images as well as sexually explicit text messages. It is estimated that ∼12% of youth aged 10 to 19 years have ever sent a sexual photo to someone else. The Internet also has created opportunities for the exploitation of children by sex offenders through social networking, chat rooms, e-mail, and online games.

Social Media and Mental Health

Research studies have identified both benefits and concerns regarding mental health and social media use. Benefits from the use of social media in moderation include the opportunity for enhanced social support and connection. Research has suggested a U-shaped relationship between Internet use and depression, with increased risks of depression at both the high and low ends of Internet use. One study found that older adolescents who used social media passively (eg, viewing others’ photos) reported declines in life satisfaction, whereas those who interacted with others and posted content did not experience these declines.Thus, in addition to the number of hours an individual spends on social media, a key factor is how social media is used.

Social Media and Privacy

Content that an adolescent chooses to post is shared with others, and the removal of such content once posted may be difficult or impossible. Adolescents vary in their understanding of privacy practices; even those who know how to set privacy settings often don’t believe they will work.Despite efforts by some social media sites to protect privacy or to delete content after it is viewed, privacy violations and unwelcome distribution are always risks.

Parent Media Use and Child Health

Social media can provide positive social experiences, such as opportunities for parents to connect with children via video-chat services. Unfortunately, some parents can be distracted by media and miss important opportunities for emotional connections that are known to improve child health.53,54 One research study found that when a parent turned his or her attention to a mobile device while with a young child, the parent was less likely to talk with the child.Parental engagement is critical in the development of children’s emotional and social development, and these distractions may have short- and long-term negative effects.

Conclusions

The effects of media use are multifactorial and depend on the type of media, the type of use, the amount and extent of use, and the characteristics of the individual child. Children today are growing up in an era of highly personalized media use experiences, so parents must develop personalized media use plans for their children that attend to each child’s age, health, temperament, and developmental stage. Research evidence shows that children and teenagers need adequate sleep, physical activity, and time away from media. Pediatricians can help families develop a Family Media Use Plan (www.HealthyChildren.org/MediaUsePlan) that prioritizes these and other health goals.

Recommendations

Pediatricians

Work with families and schools to promote understanding of the benefits and risks of media.

Promote adherence to guidelines for adequate physical activity and sleep via a Family Media Use Plan (www.HealthyChildren.org/MediaUsePlan).

Advocate for and promote information and training in media literacy.

Be aware of tools to screen for sexting, cyberbullying, problematic Internet use, and Internet gaming disorder.

Families

Develop, consistently follow, and routinely revisit a Family Media Use plan (see the plan from the American Academy of Pediatrics at www.HealthyChildren.org/MediaUsePlan).

Address what type of and how much media are used and what media behaviors are appropriate for each child or teenager, and for parents. Place consistent limits on hours per day of media use as well as types of media used.

Promote that children and adolescents get the recommended amount of daily physical activity (1 hour) and adequate sleep (8–12 hours, depending on age).

Recommend that children not sleep with devices in their bedrooms, including TVs, computers, and smartphones. Avoid exposure to devices or screens for 1 hour before bedtime.

Discourage entertainment media while doing homework.

Designate media-free times together (eg, family dinner) and media-free locations (eg, bedrooms) in homes. Promote activities that are likely to facilitate development and health, including positive parenting activities, such as reading, teaching, talking, and playing together.

Communicate guidelines to other caregivers, such as babysitters or grandparents, so that media rules are followed consistently.

Engage in selecting and co-viewing media with your child, through which your child can use media to learn and be creative, and share these experiences with your family and your community.

Have ongoing communication with children about online citizenship and safety, including treating others with respect online and offline, avoiding cyberbullying and sexting, being wary of online solicitation, and avoiding communications that can compromise personal privacy and safety.

Actively develop a network of trusted adults (eg, aunts, uncles, coaches, etc) who can engage with children through social media and to whom children can turn when they encounter challenges.

Researchers, Governmental Organizations, and Industry

Continue research into the risks and benefits of media.

Prioritize longitudinal and robust study designs, including new methodologies for understanding media exposure and use.

Today’s children and adolescents are immersed in both traditional and new forms of digital media. Research on traditional media, such as television, has identified health concerns and negative outcomes that correlate with the duration and content of viewing. Over the past decade, the use of digital media, including interactive and social media, has grown, and research evidence suggests that these newer media offer both benefits and risks to the health of children and teenagers. Evidence-based benefits identified from the use of digital and social media include early learning, exposure to new ideas and knowledge, increased opportunities for social contact and support, and new opportunities to access health promotion messages and information. Risks of such media include negative health effects on sleep, attention, and learning; a higher incidence of obesity and depression; exposure to inaccurate, inappropriate, or unsafe content and contacts; and compromised privacy and confidentiality. This technical report reviews the literature regarding these opportunities and risks, framed around clinical questions, for children from birth to adulthood. To promote health and wellness in children and adolescents, it is important to maintain adequate physical activity, healthy nutrition, good sleep hygiene, and a nurturing social environment. A healthy Family Media Use Plan (www.healthychildren.org/MediaUsePlan) that is individualized for a specific child, teenager, or family can identify an appropriate balance between screen time/online time and other activities, set boundaries for accessing content, guide displays of personal information, encourage age-appropriate critical thinking and digital literacy, and support open family communication and implementation of consistent rules about media use.

Introduction

Today’s generation of children and adolescents are growing up immersed in media, including broadcast and social media. Broadcast media include television and movies. Interactive media include social media and video games in which users can both consume and create content. Interactive media allow information sharing and provide an engaging digital environment that becomes highly personalized.

Media Use Patterns

The most common broadcast medium continues to be TV. A recent study found that TV hours among school-aged children have decreased in the past decade for children younger than 8 years.1 However, among children aged 8 years and older, average daily TV time remains over 2 hours per day.2 TV viewing also has changed over the past decade, with content available via streaming or social media sites, such as YouTube and Netflix.

Overall media use among adolescents has continued to grow over the past decade, aided by the recent increase in mobile phone use among teenagers. Approximately three-quarters of teenagers today own a smartphone,3 which allows access to the Internet, streaming TV/videos, and interactive “apps.” Approximately one-quarter of teenagers describe themselves as “constantly connected” to the Internet.

Social media sites and mobile apps provide platforms for users to create an online identity, communicate with others, and build social networks. At present, 76% of teenagers use at least 1 social media site. Although Facebook remains the most popular social media site,3 teenagers do not typically commit to just 1 social media platform; more than 70% maintain a “social media portfolio” of several selected sites, including Facebook, Twitter, and Instagram.3 Mobile apps provide a breadth of functions, such as photo sharing, games, and video-chatting.

Video games remain very popular among families; 4 of 5 households own a device used to play video games.Boys are the most avid video game players, with 91% of boys reporting having access to a game console and 84% reporting playing video games online or on a cell phone.

Benefits of Media

Both traditional and social media can provide exposure to new ideas and information, raising awareness of current events and issues. Interactive media also can provide opportunities for the promotion of community participation and civic engagement. Students can collaborate with others on assignments and projects on many online media platforms. The use of social media helps families and friends who are separated geographically communicate across the miles.

Social media can enhance access to valuable support networks, which may be particularly helpful for patients with ongoing illnesses, conditions, or disabilities.In 1 study, young adults described the benefits of seeking health information online and through social media, and recognized these channels as useful supplementary sources of information to health care visits.6 Research also supports the use of social media to foster social inclusion among users who may feel excluded or who are seeking a welcoming community: for example, those identifying as lesbian, gay, bisexual, transgender, questioning, or intersex. Finally, social media may be used to enhance wellness and promote healthy behaviors, such as smoking cessation and balanced nutrition.

Risks of Media

A first area of health concern is media use and obesity, and most studies have focused on TV. One study found that the odds of being overweight were almost 5 times greater for adolescents who watch more than 5 hours of TV per day compared with those who watch 0 to 2 hours.9 This study’s findings contributed to recommendations by the American Academy of Pediatrics that children have 2 hours or less of sedentary screen time daily. More recent studies have provided new evidence that watching TV for more than 1.5 hours daily was a risk factor for obesity, but only for children 4 through 9 years of age.10 Increased caloric intake via snacking while watching TV has been shown to be a risk factor for obesity, as is exposure to advertising for high-calorie foods and snacks.Having a TV in the bedroom continues to be associated with the risk of obesity.

Evidence suggests that media use can negatively affect sleep.Studies show that those with higher social media use15 or who sleep with mobile devices in their roomswere at greater risk of sleep disturbances. Exposure to light (particularly blue light) and activity from screens before bed affects melatonin levels and can delay or disrupt sleep.Media use around or after bedtime can disrupt sleep and negatively affect school performance.

Children who overuse online media are at risk of problematic Internet use, and heavy users of video games are at risk of Internet gaming disorder. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition,lists both as conditions in need of further research. Symptoms can include a preoccupation with the activity, decreased interest in offline or “real life” relationships, unsuccessful attempts to decrease use, and withdrawal symptoms. The prevalence of problematic Internet use among children and adolescents is between 4% and 8%,21,22 and up to 8.5% of US youth 8 to 18 years of age meet criteria for Internet gaming disorder.

At home, many children and teenagers use entertainment media at the same time that they are engaged in other tasks, such as homework.A growing body of evidence suggests that the use of media while engaged in academic tasks has negative consequences on learning.

Media Influence

Evidence gathered over decades supports links between media exposure and health behaviors among teenagers.The exposure of adolescents through media to alcohol,28,29 tobacco use,30,31 or sexual behaviors is associated with earlier initiation of these behaviors.

Adolescents’ displays on social media frequently include portrayal of health risk behaviors, such as substance use, sexual behaviors, self-injury, or disordered eating.Peer viewers of such content may see these behaviors as normative and desirable.Research from both the United States and the United Kingdom indicates that the major alcohol brands maintain a strong presence on Facebook, Twitter, and YouTube.

Cyberbullying, Sexting, and Online Solicitation

Cyberbullying and traditional bullying overlap, although online bullying presents unique challenges. These challenges include that perpetrators can be anonymous and bully at any time of day, that information can spread online rapidly, and that perpetrator and target roles can be quite fluid in the online world. Cyberbullying can lead to short- and long-term negative social, academic, and health consequences for both the perpetrator and the target. Fortunately, newer studies suggest that interventions that target bullying may reduce cyberbullying.

“Sexting” is commonly defined as the electronic transmission of nude or seminude images as well as sexually explicit text messages. It is estimated that ∼12% of youth aged 10 to 19 years have ever sent a sexual photo to someone else. The Internet also has created opportunities for the exploitation of children by sex offenders through social networking, chat rooms, e-mail, and online games.

Social Media and Mental Health

Research studies have identified both benefits and concerns regarding mental health and social media use. Benefits from the use of social media in moderation include the opportunity for enhanced social support and connection. Research has suggested a U-shaped relationship between Internet use and depression, with increased risks of depression at both the high and low ends of Internet use. One study found that older adolescents who used social media passively (eg, viewing others’ photos) reported declines in life satisfaction, whereas those who interacted with others and posted content did not experience these declines.Thus, in addition to the number of hours an individual spends on social media, a key factor is how social media is used.

Social Media and Privacy

Content that an adolescent chooses to post is shared with others, and the removal of such content once posted may be difficult or impossible. Adolescents vary in their understanding of privacy practices; even those who know how to set privacy settings often don’t believe they will work.Despite efforts by some social media sites to protect privacy or to delete content after it is viewed, privacy violations and unwelcome distribution are always risks.

Parent Media Use and Child Health

Social media can provide positive social experiences, such as opportunities for parents to connect with children via video-chat services. Unfortunately, some parents can be distracted by media and miss important opportunities for emotional connections that are known to improve child health.53,54 One research study found that when a parent turned his or her attention to a mobile device while with a young child, the parent was less likely to talk with the child.Parental engagement is critical in the development of children’s emotional and social development, and these distractions may have short- and long-term negative effects.

Conclusions

The effects of media use are multifactorial and depend on the type of media, the type of use, the amount and extent of use, and the characteristics of the individual child. Children today are growing up in an era of highly personalized media use experiences, so parents must develop personalized media use plans for their children that attend to each child’s age, health, temperament, and developmental stage. Research evidence shows that children and teenagers need adequate sleep, physical activity, and time away from media. Pediatricians can help families develop a Family Media Use Plan (www.HealthyChildren.org/MediaUsePlan) that prioritizes these and other health goals.

Recommendations

Pediatricians

Work with families and schools to promote understanding of the benefits and risks of media.

Promote adherence to guidelines for adequate physical activity and sleep via a Family Media Use Plan (www.HealthyChildren.org/MediaUsePlan).

Advocate for and promote information and training in media literacy.

Be aware of tools to screen for sexting, cyberbullying, problematic Internet use, and Internet gaming disorder.

Families

Develop, consistently follow, and routinely revisit a Family Media Use plan (see the plan from the American Academy of Pediatrics at www.HealthyChildren.org/MediaUsePlan).

Address what type of and how much media are used and what media behaviors are appropriate for each child or teenager, and for parents. Place consistent limits on hours per day of media use as well as types of media used.

Promote that children and adolescents get the recommended amount of daily physical activity (1 hour) and adequate sleep (8–12 hours, depending on age).

Recommend that children not sleep with devices in their bedrooms, including TVs, computers, and smartphones. Avoid exposure to devices or screens for 1 hour before bedtime.

Discourage entertainment media while doing homework.

Designate media-free times together (eg, family dinner) and media-free locations (eg, bedrooms) in homes. Promote activities that are likely to facilitate development and health, including positive parenting activities, such as reading, teaching, talking, and playing together.

Communicate guidelines to other caregivers, such as babysitters or grandparents, so that media rules are followed consistently.

Engage in selecting and co-viewing media with your child, through which your child can use media to learn and be creative, and share these experiences with your family and your community.

Have ongoing communication with children about online citizenship and safety, including treating others with respect online and offline, avoiding cyberbullying and sexting, being wary of online solicitation, and avoiding communications that can compromise personal privacy and safety.

Actively develop a network of trusted adults (eg, aunts, uncles, coaches, etc) who can engage with children through social media and to whom children can turn when they encounter challenges.

Researchers, Governmental Organizations, and Industry

Continue research into the risks and benefits of media.

Prioritize longitudinal and robust study designs, including new methodologies for understanding media exposure and use.

Infants, toddlers, and preschoolers are now growing up in environments saturated with a variety of traditional and new technologies, which they are adopting at increasing rates. Although there has been much hope for the educational potential of interactive media for young children, accompanied by fears about their overuse during this crucial period of rapid brain development, research in this area still remains limited. This policy statement reviews the existing literature on television, videos, and mobile/interactive technologies; their potential for educational benefit; and related health concerns for young children (0 to 5 years of age). The statement also highlights areas in which pediatric providers can offer specific guidance to families in managing their young children’s media use, not only in terms of content or time limits, but also emphasizing the importance of parent–child shared media use and allowing the child time to take part in other developmentally healthy activities.

Introduction

Technologic innovation has transformed media and its role in the lives of infants and young children. More children, even in economically challenged households, are using newer digital technologies, such as interactive and mobile media, on a daily basis1 and continue to be the target of intense marketing. This policy statement addresses the influence of media on the health and development of children from 0 to 5 years of age, a time of critical brain development, building secure relationships, and establishing health behaviors.

Infants and Toddlers

Children younger than 2 years need hands-on exploration and social interaction with trusted caregivers to develop their cognitive, language, motor, and social-emotional skills. Because of their immature symbolic, memory, and attentional skills, infants and toddlers cannot learn from traditional digital media as they do from interactions with caregivers,and they have difficulty transferring that knowledge to their 3-dimensional experience.The chief factor that facilitates toddlers’ learning from commercial media (starting around 15 months of age) is parents watching with them and reteaching the content.

The interactivity of touchscreens enables applications (apps) to identify when a child responds accurately and then tailor its responses, thereby supporting children at their levels of competence. Emerging evidence shows that at 24 months of age, children can learn words from live video-chatting with a responsive adult or from an interactive touchscreen interface that scaffolds the child to choose the relevant answers. Starting at 15 months of age, toddlers can learn novel words from touchscreens in laboratory-based studies but have trouble transferring this knowledge to the 3-dimensional world. However, it should be noted that these experiments used specially designed apps that are not commercially available.

Many parents now use video-chat (eg, Skype, FaceTime) as an interactive media form that facilitates social connection with distant relatives. New evidence shows that infants and toddlers regularly engage in video-chatting, but the same principles regarding need for parental support would apply in order for infants and toddlers to understand what they are seeing.

In summary, for children younger than 2 years, evidence for benefits of media is still limited, adult interaction with the child during media use is crucial, and there continues to be evidence of harm from excessive digital media use, as described later in this statement.

Preschool Media and Learning

Well-designed television programs, such as Sesame Street, can improve cognitive, literacy, and social outcomes for children 3 to 5 years of age and continue to create programming that addresses evolving child health and developmental needs (eg, obesity prevention, resilience). Evaluations of apps from Sesame Workshop and the Public Broadcasting Service (PBS) also have shown efficacy in teaching literacy skills to preschoolers.Unfortunately, most apps parents find under the “educational” category in app stores have no such evidence of efficacy, target only rote academic skills, are not based on established curricula, and use little or no input from developmental specialists or educators. Most apps also generally are not designed for a dual audience (ie, both parent and child). It is important to emphasize to parents that the higher-order thinking skills and executive functions essential for school success, such as task persistence, impulse control, emotion regulation, and creative, flexible thinking, are best taught through unstructured and social (not digital) play,as well as responsive parent–child interactions.

Digital books (also called “eBooks,” books that can be read on a screen) often come with interactive enhancements that, research suggests, may decrease child comprehension of content or parent dialogic reading interactions when visual effects are distracting.Parents should, therefore, be instructed to interact with children during eBook reading, as they would a print book.

Health and Developmental Concerns

Obesity

Heavy media use during preschool years is associated with small but significant increases in BMI,18 may explain disparities in obesity risk in minority children,19 and sets the stage for weight gain later in childhood.Although many studies have used a 2-hour cutoff to examine obesity risk, a recent study of 2-year-olds found that BMI increased for every hour per week of media consumed.It is believed that exposure to food advertising and watching television while eating (which diminishes attention to satiety cues) drives these associations.

Sleep

Increased duration of media exposure and the presence of a television, computer, or mobile device in the bedroom in early childhood have been associated with fewer minutes of sleep per night.

Even infants exposed to screen media in the evening hours show significantly shorter night-time sleep duration than those with no evening screen exposure. Mechanisms underlying this association include arousing content and suppression of endogenous melatonin by blue light emitted from screens.

Child Development

Population-based studies continue to show associations between excessive television viewing in early childhood and cognitive,language,and social/emotional delays, likely secondary to decreases in parent–child interaction when the television is on37 and poorer family functioning in households with high media use. An earlier age of media use onset, greater cumulative hours of media use, and non-PBS content all are significant independent predictors of poor executive functioning in preschoolers.Content is crucial: experimental evidence shows that switching from violent content to educational/prosocial content results in significant improvement in behavioral symptoms, particularly for low-income boys.Notably, the quality of parenting can modify associations between media use and child development: one study found that inappropriate content and inconsistent parenting had cumulative negative effects on low-income preschoolers’ executive function, whereas warm parenting and educational content interacted to produce additive benefits.

Child characteristics also may influence how much media children consume: excessive television viewing is more likely in infants and toddlers with a difficult temperamentor self-regulation problems, and toddlers with social-emotional delays are more likely to be given a mobile device to calm them down.

Parental Media Use

Parents’ background television use distracts from parent–child interactions and child play.Heavy parent use of mobile devices is associated with fewer verbal and nonverbal interactions between parents and children and may be associated with more parent-child conflict. Because parent media use is a strong predictor of child media habits,reducing parental media use and enhancing parent–child interactions may be an important area of behavior change.

Conclusions: Clinical Implications

In summary, multiple developmental and health concerns continue to exist for young children using all forms of digital media to excess. Evidence is sufficient to recommend time limitations on digital media use for children 2 to 5 years to no more than 1 hour per day to allow children ample time to engage in other activities important to their health and development and to establish media viewing habits associated with lower risk of obesity later in life.In addition, encouraging parents to change to educational and prosocial content and engage with their children around technology will allow children to reap the most benefit from what they view.

As digital technologies become more ubiquitous, pediatric providers must guide parents not only on the duration and content of media their child uses, but also on (1) creating unplugged spaces and times in their homes, because devices can now be taken anywhere; (2) the ability of new technologies to be used in social and creative ways; and (3) the importance of not displacing sleep, exercise, play, reading aloud, and social interactions. Realistically, pediatric providers will need to know how to help parents find resources finding appropriate content, tools for monitoring or limiting child use, ideas for play or activities in which to engage rather than digital play, and how parents can limit their own media use (see HealthyChildren.org for examples); each of these can be built into the Family Media Use Plan (see the American Academy of Pediatrics guide to developing a plan at www.healthychildren.org/MediaUsePlan).

Recommendations

Pediatricians

Start the conversation early. Ask parents of infants and young children about family media use, their children’s use habits, and media use locations.

Help families develop a Family Media Use Plan (www.healthychildren.org/MediaUsePlan) with specific guidelines for each child and parent.

Educate parents about brain development in the early years and the importance of hands-on, unstructured, and social play to build language, cognitive, and social-emotional skills.

For children younger than 18 months, discourage use of screen media other than video-chatting.

For parents of children 18 to 24 months of age who want to introduce digital media, advise that they choose high-quality programming/apps and use them together with children, because this is how toddlers learn best. Letting children use media by themselves should be avoided.

In children older than 2 years, limit media to 1 hour or less per day of high-quality programming. Recommend shared use between parent and child to promote enhanced learning, greater interaction, and limit setting.

Avoid digital media use (except video-chatting) in children younger than 18 to 24 months.

For children ages 18 to 24 months of age, if you want to introduce digital media, choose high-quality programming and use media together with your child. Avoid solo media use in this age group.

Do not feel pressured to introduce technology early; interfaces are so intuitive that children will figure them out quickly once they start using them at home or in school.

For children 2 to 5 years of age, limit screen use to 1 hour per day of high-quality programming, coview with your children, help children understand what they are seeing, and help them apply what they learn to the world around them.

Avoid fast-paced programs (young children do not understand them as well), apps with lots of distracting content, and any violent content.

Turn off televisions and other devices when not in use.

Avoid using media as the only way to calm your child. Although there are intermittent times (eg, medical procedures, airplane flights) when media is useful as a soothing strategy, there is concern that using media as strategy to calm could lead to problems with limit setting or the inability of children to develop their own emotion regulation. Ask your pediatrician for help if needed.

Monitor children’s media content and what apps are used or downloaded. Test apps before the child uses them, play together, and ask the child what he or she thinks about the app.

Keep bedrooms, mealtimes, and parent–child playtimes screen free for children and parents. Parents can set a “do not disturb” option on their phones during these times.

No screens 1 hour before bedtime, and remove devices from bedrooms before bed.

Consult the American Academy of Pediatrics Family Media Use Plan, available at: www.healthychildren.org/MediaUsePlan.

Industry

Work with developmental psychologists and educators to create design interfaces that are appropriate to child developmental abilities, that are not distracting, and that promote shared parent–child media use and application of skills to the real world. Cease making apps for children younger than 18 months until evidence of benefit is demonstrated.

Formally and scientifically evaluate products before making educational claims.

Make high-quality products accessible and affordable to low-income families and in multiple languages.

Eliminate advertising and unhealthy messages on apps. Children at this age cannot differentiate between advertisements and factual information, and therefore, advertising to them is unethical.

Help parents to set limits by stopping auto-advance of videos as the default setting. Develop systems embedded in devices that can help parents monitor and limit media use.

Infants, toddlers, and preschoolers are now growing up in environments saturated with a variety of traditional and new technologies, which they are adopting at increasing rates. Although there has been much hope for the educational potential of interactive media for young children, accompanied by fears about their overuse during this crucial period of rapid brain development, research in this area still remains limited. This policy statement reviews the existing literature on television, videos, and mobile/interactive technologies; their potential for educational benefit; and related health concerns for young children (0 to 5 years of age). The statement also highlights areas in which pediatric providers can offer specific guidance to families in managing their young children’s media use, not only in terms of content or time limits, but also emphasizing the importance of parent–child shared media use and allowing the child time to take part in other developmentally healthy activities.

Introduction

Technologic innovation has transformed media and its role in the lives of infants and young children. More children, even in economically challenged households, are using newer digital technologies, such as interactive and mobile media, on a daily basis1 and continue to be the target of intense marketing. This policy statement addresses the influence of media on the health and development of children from 0 to 5 years of age, a time of critical brain development, building secure relationships, and establishing health behaviors.

Infants and Toddlers

Children younger than 2 years need hands-on exploration and social interaction with trusted caregivers to develop their cognitive, language, motor, and social-emotional skills. Because of their immature symbolic, memory, and attentional skills, infants and toddlers cannot learn from traditional digital media as they do from interactions with caregivers,and they have difficulty transferring that knowledge to their 3-dimensional experience.The chief factor that facilitates toddlers’ learning from commercial media (starting around 15 months of age) is parents watching with them and reteaching the content.

The interactivity of touchscreens enables applications (apps) to identify when a child responds accurately and then tailor its responses, thereby supporting children at their levels of competence. Emerging evidence shows that at 24 months of age, children can learn words from live video-chatting with a responsive adult or from an interactive touchscreen interface that scaffolds the child to choose the relevant answers. Starting at 15 months of age, toddlers can learn novel words from touchscreens in laboratory-based studies but have trouble transferring this knowledge to the 3-dimensional world. However, it should be noted that these experiments used specially designed apps that are not commercially available.

Many parents now use video-chat (eg, Skype, FaceTime) as an interactive media form that facilitates social connection with distant relatives. New evidence shows that infants and toddlers regularly engage in video-chatting, but the same principles regarding need for parental support would apply in order for infants and toddlers to understand what they are seeing.

In summary, for children younger than 2 years, evidence for benefits of media is still limited, adult interaction with the child during media use is crucial, and there continues to be evidence of harm from excessive digital media use, as described later in this statement.

Preschool Media and Learning

Well-designed television programs, such as Sesame Street, can improve cognitive, literacy, and social outcomes for children 3 to 5 years of age and continue to create programming that addresses evolving child health and developmental needs (eg, obesity prevention, resilience). Evaluations of apps from Sesame Workshop and the Public Broadcasting Service (PBS) also have shown efficacy in teaching literacy skills to preschoolers.Unfortunately, most apps parents find under the “educational” category in app stores have no such evidence of efficacy, target only rote academic skills, are not based on established curricula, and use little or no input from developmental specialists or educators. Most apps also generally are not designed for a dual audience (ie, both parent and child). It is important to emphasize to parents that the higher-order thinking skills and executive functions essential for school success, such as task persistence, impulse control, emotion regulation, and creative, flexible thinking, are best taught through unstructured and social (not digital) play,as well as responsive parent–child interactions.

Digital books (also called “eBooks,” books that can be read on a screen) often come with interactive enhancements that, research suggests, may decrease child comprehension of content or parent dialogic reading interactions when visual effects are distracting.Parents should, therefore, be instructed to interact with children during eBook reading, as they would a print book.

Health and Developmental Concerns

Obesity

Heavy media use during preschool years is associated with small but significant increases in BMI,18 may explain disparities in obesity risk in minority children,19 and sets the stage for weight gain later in childhood.Although many studies have used a 2-hour cutoff to examine obesity risk, a recent study of 2-year-olds found that BMI increased for every hour per week of media consumed.It is believed that exposure to food advertising and watching television while eating (which diminishes attention to satiety cues) drives these associations.

Sleep

Increased duration of media exposure and the presence of a television, computer, or mobile device in the bedroom in early childhood have been associated with fewer minutes of sleep per night.

Even infants exposed to screen media in the evening hours show significantly shorter night-time sleep duration than those with no evening screen exposure. Mechanisms underlying this association include arousing content and suppression of endogenous melatonin by blue light emitted from screens.

Child Development

Population-based studies continue to show associations between excessive television viewing in early childhood and cognitive,language,and social/emotional delays, likely secondary to decreases in parent–child interaction when the television is on37 and poorer family functioning in households with high media use. An earlier age of media use onset, greater cumulative hours of media use, and non-PBS content all are significant independent predictors of poor executive functioning in preschoolers.Content is crucial: experimental evidence shows that switching from violent content to educational/prosocial content results in significant improvement in behavioral symptoms, particularly for low-income boys.Notably, the quality of parenting can modify associations between media use and child development: one study found that inappropriate content and inconsistent parenting had cumulative negative effects on low-income preschoolers’ executive function, whereas warm parenting and educational content interacted to produce additive benefits.

Child characteristics also may influence how much media children consume: excessive television viewing is more likely in infants and toddlers with a difficult temperamentor self-regulation problems, and toddlers with social-emotional delays are more likely to be given a mobile device to calm them down.

Parental Media Use

Parents’ background television use distracts from parent–child interactions and child play.Heavy parent use of mobile devices is associated with fewer verbal and nonverbal interactions between parents and children and may be associated with more parent-child conflict. Because parent media use is a strong predictor of child media habits,reducing parental media use and enhancing parent–child interactions may be an important area of behavior change.

Conclusions: Clinical Implications

In summary, multiple developmental and health concerns continue to exist for young children using all forms of digital media to excess. Evidence is sufficient to recommend time limitations on digital media use for children 2 to 5 years to no more than 1 hour per day to allow children ample time to engage in other activities important to their health and development and to establish media viewing habits associated with lower risk of obesity later in life.In addition, encouraging parents to change to educational and prosocial content and engage with their children around technology will allow children to reap the most benefit from what they view.

As digital technologies become more ubiquitous, pediatric providers must guide parents not only on the duration and content of media their child uses, but also on (1) creating unplugged spaces and times in their homes, because devices can now be taken anywhere; (2) the ability of new technologies to be used in social and creative ways; and (3) the importance of not displacing sleep, exercise, play, reading aloud, and social interactions. Realistically, pediatric providers will need to know how to help parents find resources finding appropriate content, tools for monitoring or limiting child use, ideas for play or activities in which to engage rather than digital play, and how parents can limit their own media use (see HealthyChildren.org for examples); each of these can be built into the Family Media Use Plan (see the American Academy of Pediatrics guide to developing a plan at www.healthychildren.org/MediaUsePlan).

Recommendations

Pediatricians

Start the conversation early. Ask parents of infants and young children about family media use, their children’s use habits, and media use locations.

Help families develop a Family Media Use Plan (www.healthychildren.org/MediaUsePlan) with specific guidelines for each child and parent.

Educate parents about brain development in the early years and the importance of hands-on, unstructured, and social play to build language, cognitive, and social-emotional skills.

For children younger than 18 months, discourage use of screen media other than video-chatting.

For parents of children 18 to 24 months of age who want to introduce digital media, advise that they choose high-quality programming/apps and use them together with children, because this is how toddlers learn best. Letting children use media by themselves should be avoided.

In children older than 2 years, limit media to 1 hour or less per day of high-quality programming. Recommend shared use between parent and child to promote enhanced learning, greater interaction, and limit setting.

Avoid digital media use (except video-chatting) in children younger than 18 to 24 months.

For children ages 18 to 24 months of age, if you want to introduce digital media, choose high-quality programming and use media together with your child. Avoid solo media use in this age group.

Do not feel pressured to introduce technology early; interfaces are so intuitive that children will figure them out quickly once they start using them at home or in school.

For children 2 to 5 years of age, limit screen use to 1 hour per day of high-quality programming, coview with your children, help children understand what they are seeing, and help them apply what they learn to the world around them.

Avoid fast-paced programs (young children do not understand them as well), apps with lots of distracting content, and any violent content.

Turn off televisions and other devices when not in use.

Avoid using media as the only way to calm your child. Although there are intermittent times (eg, medical procedures, airplane flights) when media is useful as a soothing strategy, there is concern that using media as strategy to calm could lead to problems with limit setting or the inability of children to develop their own emotion regulation. Ask your pediatrician for help if needed.

Monitor children’s media content and what apps are used or downloaded. Test apps before the child uses them, play together, and ask the child what he or she thinks about the app.

Keep bedrooms, mealtimes, and parent–child playtimes screen free for children and parents. Parents can set a “do not disturb” option on their phones during these times.

No screens 1 hour before bedtime, and remove devices from bedrooms before bed.

Consult the American Academy of Pediatrics Family Media Use Plan, available at: www.healthychildren.org/MediaUsePlan.

Industry

Work with developmental psychologists and educators to create design interfaces that are appropriate to child developmental abilities, that are not distracting, and that promote shared parent–child media use and application of skills to the real world. Cease making apps for children younger than 18 months until evidence of benefit is demonstrated.

Formally and scientifically evaluate products before making educational claims.

Make high-quality products accessible and affordable to low-income families and in multiple languages.

Eliminate advertising and unhealthy messages on apps. Children at this age cannot differentiate between advertisements and factual information, and therefore, advertising to them is unethical.

Help parents to set limits by stopping auto-advance of videos as the default setting. Develop systems embedded in devices that can help parents monitor and limit media use.

Researchers are calling for a nationwide ban on crib bumpers after finding they are linked to a growing number of infant deaths.

Twenty-three deaths related to crib bumpers were reported to the U.S. Consumer Product Safety Commission (CPSC) from 2006 through 2012, according to the report “Crib Bumpers Continue to Cause Infant Deaths: A Need for a New Preventive Approach.” Eight deaths were reported in each of the three previous seven-year periods.

“Crib bumpers are killing kids,” senior author Bradley T. Thach, M.D., professor emeritus of pediatrics at the Washington University School of Medicine, said in a news release. “Bumpers are more dangerous than we originally thought. The infant deaths we studied could have been prevented if the cribs were empty.”

There were 48 deaths related to crib bumpers from 1985 through 2012, most due to suffocation, according to a review of CPSC data detailed in the report (Scheers NJ, et al. J Pediatr. Nov. 24, 2015, www.sciencedirect.com/science/article/pii/S0022347615012846). In an additional 146 incidents, babies nearly suffocated or choked.

Researchers acknowledged the increase over previous years could be due in part to better reporting to CPSC but also said they believe the actual figures may be higher as they found additional bumper-related deaths when reviewing data from the National Center for the Review and Prevention of Child Deaths.

The Academy, the National Institutes of Health and the Centers for Disease Control and Prevention all recommend against bumpers, but there are no federal regulations regarding their use. Researchers, two of whom previously worked for the CPSC, said that agency would be responsible for instituting a ban, but it has limited resources.

“A ban on crib bumpers would reinforce the message that no soft bedding of any kind should be placed inside a baby's crib,” Dr. Thach said. "There is one sure-fire way to prevent infant deaths from crib bumpers: Don't use them, ever."

Researchers are calling for a nationwide ban on crib bumpers after finding they are linked to a growing number of infant deaths.

Twenty-three deaths related to crib bumpers were reported to the U.S. Consumer Product Safety Commission (CPSC) from 2006 through 2012, according to the report “Crib Bumpers Continue to Cause Infant Deaths: A Need for a New Preventive Approach.” Eight deaths were reported in each of the three previous seven-year periods.

“Crib bumpers are killing kids,” senior author Bradley T. Thach, M.D., professor emeritus of pediatrics at the Washington University School of Medicine, said in a news release. “Bumpers are more dangerous than we originally thought. The infant deaths we studied could have been prevented if the cribs were empty.”

There were 48 deaths related to crib bumpers from 1985 through 2012, most due to suffocation, according to a review of CPSC data detailed in the report (Scheers NJ, et al. J Pediatr. Nov. 24, 2015, www.sciencedirect.com/science/article/pii/S0022347615012846). In an additional 146 incidents, babies nearly suffocated or choked.

Researchers acknowledged the increase over previous years could be due in part to better reporting to CPSC but also said they believe the actual figures may be higher as they found additional bumper-related deaths when reviewing data from the National Center for the Review and Prevention of Child Deaths.

The Academy, the National Institutes of Health and the Centers for Disease Control and Prevention all recommend against bumpers, but there are no federal regulations regarding their use. Researchers, two of whom previously worked for the CPSC, said that agency would be responsible for instituting a ban, but it has limited resources.

“A ban on crib bumpers would reinforce the message that no soft bedding of any kind should be placed inside a baby's crib,” Dr. Thach said. "There is one sure-fire way to prevent infant deaths from crib bumpers: Don't use them, ever."

Major achievements in pediatric research, often taken for granted, have been made possible with federal funding. A recent congressional briefing hosted by the AAP Committee on Pediatric Research highlighted discoveries from the last 40 years from the perspectives of researchers and families.
From passenger safety laws to the use of surfactant to rotavirus vaccines, pediatric research innovations over the last four decades have led to life-saving discoveries and policy changes that many take for granted.

Despite the importance of these advancements, researchers don’t always do a good job explaining the impact of their work and how it saves lives, said Tina Cheng, M.D., M.P.H., FAAP, chair of the AAP Committee on Pediatric Research (COPR).

That’s one reason the committee hosted a congressional briefing in December to present to lawmakers “7 Great Achievements in Pediatric Research” (see sidebar). Researchers and family members impacted by the research spoke to a standing-room-only crowd, focusing on innovations in the members’ lifetimes.

The topics covered immunizations, pediatric cancer, saving premature infants, preventing HIV transmission from mothers to babies, reducing sudden infant death syndrome (SIDS), increasing life expectancy for children with chronic diseases, and saving lives with car seats and seat belts. Forty years ago some of these discoveries may have seemed like science fiction.

To help select the topics, COPR surveyed its members along with the boards of the American Pediatric Society, Academic Pediatric Association, Society for Pediatric Research, Federation of Pediatric Organizations and Association of Medical School Pediatric Department Chairs. The groups, along with the Academy, sponsored the briefing.

“We chose the seven because we felt like they were recent successes and they were successes that would resonate with the public,” said Dr. Cheng, who moderated the briefing.

SPEAKING FROM THE HEART

Researchers shared their perspectives, but when family members and young people offered their stories about how research changed their lives, it was even more powerful, said neonatologist Scott Denne, M.D., FAAP, past chair of COPR.

Tokunbo Olaniyan, of Columbia, Md., a young woman whose late mother had sickle cell disease, talked about how grateful she was that her mother lived to be old enough to give birth. Forty years ago, sickle cell patients in the United States typically lived to only about 14 years.

College student Vikram Siberry, of Olney, Md., told how a seatbelt saved him during a car accident in high school that took the life of his friend who was behind the wheel.

Dr. Denne also shared how the introduction of surfactant to treat premature babies has affected his professional life.

“The difference is as night-and-day as any intervention has ever been,” he said.

“Before surfactant, our primary tools were the ventilator, and premature babies were born and immediately struggled to breathe,” he told the group. “The ventilator caused substantial damage — major ruptures of the lung — so you had to put in chest tubes. Babies needed to stay on ventilators for prolonged periods. Many babies who left the nursery had significant lung disease, and many babies simply didn’t survive.

“A daily event was babies dying … multiple chest tubes being placed … a whole host of rooms dedicated for babies who were going to be on ventilators for months. That was the reality before surfactant,” Dr. Denne said.

Today, many babies come off ventilators more quickly, lung damage is significantly less severe and survival rates have increased substantially, he noted.

SIDS was addressed by Marian Willinger, Ph.D., director of the research program in SIDS at the Eunice Kennedy Shriver National Institute for Child Health and Human Development. Dr. Willinger, consultant to the AAP Task Force on SIDS, coordinated much of the research efforts on the Back to Sleep campaign. Since 1994, the overall U.S. SIDS rate has declined by more than half as a result of babies being placed on their backs to sleep.

The briefing included graphs and charts on topics such as the progress made in life expectancy for patients with sickle cell anemia and cystic fibrosis. One chart showed the steep drop in perinatally acquired AIDS in the early 1990s with the introduction of an antiretroviral medication.

IMPORTANCE OF FUNDING

All of the stories were designed to help lawmakers and others understand the ongoing need for federal research funding.

“It’s very important for the general public to understand how impactful investing in research can and has been,” said Dr. Denne, who said funding should be maintained or better yet, increased.

Although the seven achievements will be no surprise to any pediatrician, Dr. Cheng said they all are taken for granted sometimes and continued investment is needed.

“All of these discoveries were the result of research funding innovation that led to decreased mortality, increased life expectancy, increased quality of life. There are more research discoveries to be made.”

7 Great Achievements in Pediatric Research in the Past 40 Years

Preventing disease with life-saving immunizations

Diseases like rotavirus and Haemophilus influenzae type b are now preventable due to vaccines.

Saving premature babies by helping them breathe

Deaths from respiratory distress syndrome have been reduced by two-thirds with the introduction of surfactant.

Reducing sudden infant death syndrome (SIDS) with Back to Sleep

SIDS has declined by half due to research and the Back to Sleep campaign.

Curing a common childhood cancer

More than 90% of children with acute lymphocytic leukemia now survive, compared with 57% in the 1970s.

Major achievements in pediatric research, often taken for granted, have been made possible with federal funding. A recent congressional briefing hosted by the AAP Committee on Pediatric Research highlighted discoveries from the last 40 years from the perspectives of researchers and families.
From passenger safety laws to the use of surfactant to rotavirus vaccines, pediatric research innovations over the last four decades have led to life-saving discoveries and policy changes that many take for granted.

Despite the importance of these advancements, researchers don’t always do a good job explaining the impact of their work and how it saves lives, said Tina Cheng, M.D., M.P.H., FAAP, chair of the AAP Committee on Pediatric Research (COPR).

That’s one reason the committee hosted a congressional briefing in December to present to lawmakers “7 Great Achievements in Pediatric Research” (see sidebar). Researchers and family members impacted by the research spoke to a standing-room-only crowd, focusing on innovations in the members’ lifetimes.

The topics covered immunizations, pediatric cancer, saving premature infants, preventing HIV transmission from mothers to babies, reducing sudden infant death syndrome (SIDS), increasing life expectancy for children with chronic diseases, and saving lives with car seats and seat belts. Forty years ago some of these discoveries may have seemed like science fiction.

To help select the topics, COPR surveyed its members along with the boards of the American Pediatric Society, Academic Pediatric Association, Society for Pediatric Research, Federation of Pediatric Organizations and Association of Medical School Pediatric Department Chairs. The groups, along with the Academy, sponsored the briefing.

“We chose the seven because we felt like they were recent successes and they were successes that would resonate with the public,” said Dr. Cheng, who moderated the briefing.

SPEAKING FROM THE HEART

Researchers shared their perspectives, but when family members and young people offered their stories about how research changed their lives, it was even more powerful, said neonatologist Scott Denne, M.D., FAAP, past chair of COPR.

Tokunbo Olaniyan, of Columbia, Md., a young woman whose late mother had sickle cell disease, talked about how grateful she was that her mother lived to be old enough to give birth. Forty years ago, sickle cell patients in the United States typically lived to only about 14 years.

College student Vikram Siberry, of Olney, Md., told how a seatbelt saved him during a car accident in high school that took the life of his friend who was behind the wheel.

Dr. Denne also shared how the introduction of surfactant to treat premature babies has affected his professional life.

“The difference is as night-and-day as any intervention has ever been,” he said.

“Before surfactant, our primary tools were the ventilator, and premature babies were born and immediately struggled to breathe,” he told the group. “The ventilator caused substantial damage — major ruptures of the lung — so you had to put in chest tubes. Babies needed to stay on ventilators for prolonged periods. Many babies who left the nursery had significant lung disease, and many babies simply didn’t survive.

“A daily event was babies dying … multiple chest tubes being placed … a whole host of rooms dedicated for babies who were going to be on ventilators for months. That was the reality before surfactant,” Dr. Denne said.

Today, many babies come off ventilators more quickly, lung damage is significantly less severe and survival rates have increased substantially, he noted.

SIDS was addressed by Marian Willinger, Ph.D., director of the research program in SIDS at the Eunice Kennedy Shriver National Institute for Child Health and Human Development. Dr. Willinger, consultant to the AAP Task Force on SIDS, coordinated much of the research efforts on the Back to Sleep campaign. Since 1994, the overall U.S. SIDS rate has declined by more than half as a result of babies being placed on their backs to sleep.

The briefing included graphs and charts on topics such as the progress made in life expectancy for patients with sickle cell anemia and cystic fibrosis. One chart showed the steep drop in perinatally acquired AIDS in the early 1990s with the introduction of an antiretroviral medication.

IMPORTANCE OF FUNDING

All of the stories were designed to help lawmakers and others understand the ongoing need for federal research funding.

“It’s very important for the general public to understand how impactful investing in research can and has been,” said Dr. Denne, who said funding should be maintained or better yet, increased.

Although the seven achievements will be no surprise to any pediatrician, Dr. Cheng said they all are taken for granted sometimes and continued investment is needed.

“All of these discoveries were the result of research funding innovation that led to decreased mortality, increased life expectancy, increased quality of life. There are more research discoveries to be made.”

7 Great Achievements in Pediatric Research in the Past 40 Years

Preventing disease with life-saving immunizations

Diseases like rotavirus and Haemophilus influenzae type b are now preventable due to vaccines.

Saving premature babies by helping them breathe

Deaths from respiratory distress syndrome have been reduced by two-thirds with the introduction of surfactant.

Reducing sudden infant death syndrome (SIDS) with Back to Sleep

SIDS has declined by half due to research and the Back to Sleep campaign.

Curing a common childhood cancer

More than 90% of children with acute lymphocytic leukemia now survive, compared with 57% in the 1970s.

2013年，AAP和美国家庭医师学会(American Academy of Family Physicians)发布了更新后的AOM诊断和治疗临床实践指南。22AOM的定义为：“中耳炎症状和体征的快速发作。”上述体征包括伴有或不伴有红斑的鼓膜(TM)膨出，症状可能包括耳痛、烦躁、耳漏和发热等。诊断AOM往往需要仔细的耳镜检查，以确认存在TM炎性改变。AAP指南建议，在以下任何一种情况下医生都可以确诊AOM：(1)有证据表明存在中耳积液（TM中度到重度膨出）；或(2)不能归因于外耳道炎的新发耳漏。如果患儿仅出现轻度TM膨出，但伴有最近发生的耳部疼痛或TM严重红斑，也可以确诊AOM。由于清晰地观察TM可能有困难，且AOM通常是自限性疾病，为了尽量减少抗生素滥用，必须确保诊断的高度准确性。在确诊AOM后，根据疾病的严重程度（严重耳痛，耳痛持续>48小时，或体温≥39°C）、感染的偏侧性（双侧与单侧）、以及年龄（≤23个月和≥24个月）对患者进行分类将有助于合理地使用抗生素。症状严重、双侧受累且年龄较小的患者更可能受益于抗生素。对于年龄稍大、病情不严重且为单侧发病的患者，随访观察是较为合理的处置。

2013年，AAP和美国家庭医师学会(American Academy of Family Physicians)发布了更新后的AOM诊断和治疗临床实践指南。22AOM的定义为：“中耳炎症状和体征的快速发作。”上述体征包括伴有或不伴有红斑的鼓膜(TM)膨出，症状可能包括耳痛、烦躁、耳漏和发热等。诊断AOM往往需要仔细的耳镜检查，以确认存在TM炎性改变。AAP指南建议，在以下任何一种情况下医生都可以确诊AOM：(1)有证据表明存在中耳积液（TM中度到重度膨出）；或(2)不能归因于外耳道炎的新发耳漏。如果患儿仅出现轻度TM膨出，但伴有最近发生的耳部疼痛或TM严重红斑，也可以确诊AOM。由于清晰地观察TM可能有困难，且AOM通常是自限性疾病，为了尽量减少抗生素滥用，必须确保诊断的高度准确性。在确诊AOM后，根据疾病的严重程度（严重耳痛，耳痛持续>48小时，或体温≥39°C）、感染的偏侧性（双侧与单侧）、以及年龄（≤23个月和≥24个月）对患者进行分类将有助于合理地使用抗生素。症状严重、双侧受累且年龄较小的患者更可能受益于抗生素。对于年龄稍大、病情不严重且为单侧发病的患者，随访观察是较为合理的处置。

Abstract
Oral health is an integral part of the overall health of children. Dental caries is a common and chronic disease process with significant short- and long-term consequences. The prevalence of dental caries for the youngest of children has not decreased over the past decade, despite improvements for older children. As health care professionals responsible for the overall health of children, pediatricians frequently confront morbidity associated with dental caries. Because the youngest children visit the pediatrician more often than they visit the dentist, it is important that pediatricians be knowledgeable about the disease process of dental caries, prevention of the disease, and interventions available to the pediatrician and the family to maintain and restore health.

Introduction
Dental caries is the most common chronic disease of childhood. Twenty-four percent of US children 2 to 4 years of age, 53% of children 6 to 8 years of age, and 56% of 15-year-olds have caries experience (ie, untreated dental caries, filled teeth, teeth missing as a result of dental caries). For children 5 to 19 years of age, children from poor and racial or ethnic minority families have higher rates of untreated dental caries than do their peers from nonpoor and nonminority families. For some age groups, the incidence of dental caries has decreased or stayed the same, but for the youngest children, it has increased. Among 6- to 8-year-olds and 15-year-olds, caries experience and untreated dental decay remained mostly unchanged between 1988–1994 and 1999–2004. In children 2 to 4 years of age, the caries experience increased significantly, from 19% to 24%, during that same time period. The increase in the caries experience and untreated caries was statistically significant in children from poor families.

The Etiology and Pathogenesis of Dental Caries
A dynamic process takes place at the surface of the tooth that involves constant demineralization and remineralization of the tooth enamel (the caries balance). Multiple factors affect that dynamic process and can be manipulated in ways that tip the balance toward disease (demineralization) or health (remineralization). These factors include bacteria, sugar, saliva, and fluoride. Because these factors can be manipulated, it is possible for pediatricians and families to prevent, halt, or even reverse the disease process.

Different oral structures and tissues have different and distinct microbial communities (microbiomes). The oral microbiome at the surface of the tooth is referred to as dental plaque. During the disease process of dental caries, bacteria that are aciduric and acidogenic predominate in the dental plaque. Streptococcus mutans is most strongly associated with dental caries, although other bacterial species have these capabilities and thus can also be pathogenic. When environmental factors make it possible to select for these pathogenic bacteria in dental plaque, the disease process begins.

A key environmental factor that allows for selection and proliferation of these pathogenic bacteria is dietary sugar intake. Because these pathogenic bacteria have the ability to ferment sugars, produce acid, and decrease the pH of the dental plaque, they make possible the selection of other aciduric, acidogenic bacteria that will contribute to disease. As more bacteria produce more acid, the pH at the surface of the tooth decreases. This process causes the demineralization of the tooth enamel. Unimpeded, these long periods of low pH and demineralization will result in cavitation.

Saliva is an important factor in buffering the low pH and bringing these demineralization pressures back to a balance with remineralization. In addition to acting as a buffering agent, saliva also flushes the oral cavity of food particles and provides an environment rich in calcium and phosphate to aid in remineralization. When salivary flow is impeded, the pH is able to decrease to a lower level, tipping the scales toward demineralization (disease); in addition, the time it takes to buffer back to a normal pH is longer.

Another important factor that can affect the balance of demineralization and remineralization is fluoride. More in-depth reviews of fluoride are available elsewhere. It is important, however, for pediatricians and other child health care providers to understand how fluoride influences the caries balance. Fluoride has 3 key effects on the caries balance: (1) inhibition of demineralization at the tooth surface; (2) enhancement of remineralization, which results in a more acid-resistant tooth surface; and (3) inhibition of bacterial enzymes. The primary effect of fluoride is topical, via fluoridated toothpastes, mouth rinses, and varnishes, although there is still value in systemic fluoride exposures via fluoridated water and supplements.

Preventive Strategies

Caries Risk Assessment

Ideally, primary prevention efforts will anticipate and prevent caries before the first sign of disease. Preventive strategies for this multifactorial, chronic disease require a comprehensive and multifocal approach that begins with caries risk assessment. Assessing each child’s risk of caries and tailoring preventive strategies to specific risk factors are necessary for maintaining and improving oral health. There is no single test that takes into consideration all risk factors and accurately predicts an individual's susceptibility to caries. However, pediatricians can conduct an excellent risk assessment for caries by focusing on the key risk factors for dental caries that are associated with diet, bacteria, saliva, and status of the teeth (both current status and previous caries experience). The American Academy of Pediatrics (AAP)/Bright Futures Oral Health Risk Assessment Tool can be found at http://www2.aap.org/oralhealth ... html.

Sugars (but not sugar substitutes) are a critical risk factor in the development of caries. The risk of caries is greatest if sugars are consumed at high frequency and are in a form that remains in the mouth for long periods of time. Thus, key behaviors that place a child at high risk of caries include continual bottle/sippy cup use (especially with fluids other than water), sleeping with a bottle (especially with fluids other than water), frequent between-meal snacks of sugars/cooked starch/sugared beverages, and frequent intake of sugared medications.

Early acquisition of S mutans is a major risk factor for early childhood caries and future caries experience. Strong evidence demonstrates that mothers are a primary source of S mutans colonization for their children. Thus, an important factor associated with caries risk in young children is the recent or current presence of active dental decay in the primary caregiver. Prevention, diagnosis, and treatment of oral diseases are highly beneficial, can be undertaken, and should be encouraged during pregnancy with no additional fetal or maternal risk compared with the risk of not providing care. The most important and predictive risk factor for caries, however, is previous caries experience. This finding is not surprising, considering that the factors which initiated the disease process often continue to exist over time.

Other caries risk factors are associated with salivary flow and the status of the teeth. Diseases (eg, diabetes mellitus, Sjögren's syndrome, cystic fibrosis) and medications (eg, antihistamines, anticonvulsants, antidepressants) that result in xerostomia (decreased salivary flow) reduce the availability of saliva to buffer the acid produced by pathogenic bacteria, thus enhancing their ability to cause damage to the teeth. In addition, the teeth of preterm infants, which frequently have enamel defects, are at increased susceptibility for disease. Older children who have deep pits and fissures in their molars are also at increased susceptibility for disease.

Anticipatory Guidance
With a clear understanding of the etiology of dental caries and the risk factors that lead to and facilitate the spread of this disease, pediatricians can target anticipatory guidance to assist families in preventing it. Because the disease of dental caries is multifocal, the anticipatory guidance should also be multifocal. Pediatricians should concentrate their anticipatory guidance on topics that can affect the risk of disease.

Dietary Counseling
Because sugar intake is such an important risk factor for dental caries, pediatricians can incorporate anticipatory guidance associated with preventing dental caries into discussions with families about dietary habits and nutritional intake. Pediatricians should counsel parents and caregivers on the importance of reducing the frequency of exposure to sugars in foods and drinks. To decrease the risk of dental caries and ensure the best possible health and developmental outcomes, pediatricians should recommend that parents do the following:

•Exclusively breastfeed infants for 6 months and continue breastfeeding as complementary foods are introduced for 1 year or longer, as mutually desired by mother and infant.

•Discourage putting a child to bed with a bottle. Establish a bedtime routine conducive to optimal oral health (eg, brush, book, and bed).

•Wean from a bottle by 1 year of age.

•Limit sugary foods and drinks to mealtimes.

•Avoid carbonated, sugared beverages and juice drinks that are not 100% juice.

•Limit the intake of 100% fruit juice to no more than 4 to 6 oz per day.

•Encourage children to drink only water between meals, preferably fluoridated tap water.

•Foster eating patterns that are consistent with guidelines from the US Department of Agriculture.

Oral Hygiene
The value of good oral hygiene lies in controlling the levels and activity of disease-causing bacteria in the oral cavity and delivering fluoride to the surface of the tooth. It is important to remember that pathogenic bacteria can be passed from caregiver to child. Thus, anticipatory guidance for both parent and child is important. Key anticipatory guidance points regarding oral hygiene are as follows:

•Parents/caregivers should be encouraged to model and maintain good oral hygiene and a relationship with their own dental provider.

•Parents/caregivers, especially those with significant history of dental decay, should be cautioned to avoid sharing with their child items that have been in their own mouths.

•The child’s teeth should be brushed twice a day as soon as the teeth erupt with a smear or a grain-of-rice–sized amount of fluoridated toothpaste. After the third birthday, a pea-sized amount should be used.

•Parents/caregivers should help/supervise a child brushing his or her teeth until mastery is obtained, usually at around 8 years of age.

Fluoride
The delivery of fluoride to the teeth includes community-based options (water fluoridation), self-administered modalities (fluoride toothpaste and supplements), and professional applications (fluoride varnish). Each of these delivery mechanisms is useful in preventing dental caries.

Water fluoridation is a community-based intervention that optimizes the level of fluoride in drinking water, resulting in preeruptive and posteruptive protection of the teeth.19 Water fluoridation is a cost-effective means of preventing dental caries, with the lifetime cost per person equaling less than the cost of 1 dental restoration. Most bottled waters do not contain an adequate amount of fluoride.

Fluoride toothpaste is an important way to deliver fluoride to the surface of the tooth. Fluoride toothpaste has been shown to be effective in reducing dental caries in both primary and permanent teeth. It is important to limit the amount of toothpaste used to a smear or a grain-of-rice–sized amount for young children and no more than a pea-sized amount for children older than 3 years. Fluoride supplements should be prescribed for children whose primary source of drinking water is deficient in fluoride.

Fluoride varnish is a professionally applied, sticky resin of highly concentrated fluoride. Two or more applications of fluoride varnish per year are effective in preventing caries in children at high risk of all ages. In most states, pediatricians can apply and be paid for application of fluoride varnish to the teeth of young children. Application of fluoride varnish is even more effective when coupled with counseling. The US Preventive Services Task Force recently published a new recommendation that primary care clinicians apply fluoride varnish to the primary teeth of all infants and children starting at the age of primary tooth eruption (B recommendation). More details and recommendations on fluoride can be found in the AAP clinical report “Fluoride Use in Caries Prevention in the Primary Care Setting.”

Other Important Anticipatory Guidance Topics
A frequent topic of discussion with parents is nonnutritive oral habits, such as use of pacifiers and thumb sucking. AAP policy states that parents consider offering a pacifier at naptime and bedtime because of a protective effect of pacifiers on the incidence of sudden infant death syndrome after the first month of life.27 Both finger- and pacifier-sucking habits will only cause problems with dental structures if they go on for a long period of time. Evaluation by a dentist is indicated for nonnutritive sucking habits that continue beyond 3 years of age.28

Dental injuries are common. Twenty-five percent of all schoolchildren experience some form of dental trauma. Pediatricians can help prevent such trauma by encouraging parents to cover sharp corners of household furnishings at the level of walking toddlers, recommend use of car safety seats, and be aware of electrical cord risk for mouth injury. Pediatricians can also encourage mouthguard use during sports activities in which there is a significant risk of orofacial injury.More information on dental trauma is available in the AAP clinical report “Management of Dental Trauma in a Primary Care Setting.”

Collaboration With Dental Providers
The AAP, the American Academy of Pediatric Dentistry, the American Dental Association, and the American Association of Public Health Dentistry all recommend a dental visit for children by 1 year of age. Although pediatricians have the opportunity to provide early assessment of risk for dental caries and anticipatory guidance to prevent disease, it is also important that children establish a dental home. A dental home is the ongoing relationship between the dentist and the patient, inclusive of all aspects of oral health care delivered in a comprehensive, continuously accessible, coordinated, and family-centered way.

Unfortunately, little is known about pediatric health care providers’ dental referral behaviors and patterns. Although 1 study found that children 2 to 5 years of age who received a recommendation from their health care provider to visit the dentist were more likely to have a dental visit, the US Preventive Services Task Force found no study that evaluated the effects of referral by a primary care clinician to a dentist on caries incidence. It is also noteworthy that preschool-aged children covered by Medicaid who had an early preventive dental visit by 1 year of age were more likely to use subsequent preventive services and to have lower dental expenses.

With early referral to a dental provider, there is an opportunity to maintain good oral health, prevent disease, and treat disease early. Establishing such collaborative relationships between physicians and dentists at the community level is essential for increasing access to dental care for all children and improving their oral and overall health.

Conclusions
Oral health is an integral part of the overall health and well-being of children. A pediatrician who is familiar with the science of dental caries, capable of assessing caries risk, comfortable with applying various strategies of prevention and intervention, and connected to dental resources can contribute considerably to the health of his or her patients. This policy statement, in conjunction with the oral health recommendations of the third edition of the AAP's Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, serves as a resource for pediatricians and other pediatric primary care providers to be knowledgeable about addressing dental caries. Because dental caries is such a common and consequential disease process in the pediatric population, it is essential that pediatricians include oral health in their daily practice of pediatrics.

Suggestions for Pediatricians

1.Administer an oral health risk assessment periodically to all children.

2.Include anticipatory guidance for oral health as an integral part of comprehensive patient counseling.

3.Counsel parents/caregivers and patients to reduce the frequency of exposure to sugars in foods and drinks.

4.Encourage parents/caregivers to brush a child’s teeth as soon as teeth erupt with a smear or a grain-of-rice–sized amount of fluoride toothpaste and a pea-sized amount at 3 years of age.

5.Advise parents/caregivers to monitor brushing until 8 years of age.

6.Refer to the AAP clinical report, “Fluoride Use in Caries Prevention in the Primary Care Setting,” for fluoride administration and supplementation decisions.

Abstract
Oral health is an integral part of the overall health of children. Dental caries is a common and chronic disease process with significant short- and long-term consequences. The prevalence of dental caries for the youngest of children has not decreased over the past decade, despite improvements for older children. As health care professionals responsible for the overall health of children, pediatricians frequently confront morbidity associated with dental caries. Because the youngest children visit the pediatrician more often than they visit the dentist, it is important that pediatricians be knowledgeable about the disease process of dental caries, prevention of the disease, and interventions available to the pediatrician and the family to maintain and restore health.

Introduction
Dental caries is the most common chronic disease of childhood. Twenty-four percent of US children 2 to 4 years of age, 53% of children 6 to 8 years of age, and 56% of 15-year-olds have caries experience (ie, untreated dental caries, filled teeth, teeth missing as a result of dental caries). For children 5 to 19 years of age, children from poor and racial or ethnic minority families have higher rates of untreated dental caries than do their peers from nonpoor and nonminority families. For some age groups, the incidence of dental caries has decreased or stayed the same, but for the youngest children, it has increased. Among 6- to 8-year-olds and 15-year-olds, caries experience and untreated dental decay remained mostly unchanged between 1988–1994 and 1999–2004. In children 2 to 4 years of age, the caries experience increased significantly, from 19% to 24%, during that same time period. The increase in the caries experience and untreated caries was statistically significant in children from poor families.

The Etiology and Pathogenesis of Dental Caries
A dynamic process takes place at the surface of the tooth that involves constant demineralization and remineralization of the tooth enamel (the caries balance). Multiple factors affect that dynamic process and can be manipulated in ways that tip the balance toward disease (demineralization) or health (remineralization). These factors include bacteria, sugar, saliva, and fluoride. Because these factors can be manipulated, it is possible for pediatricians and families to prevent, halt, or even reverse the disease process.

Different oral structures and tissues have different and distinct microbial communities (microbiomes). The oral microbiome at the surface of the tooth is referred to as dental plaque. During the disease process of dental caries, bacteria that are aciduric and acidogenic predominate in the dental plaque. Streptococcus mutans is most strongly associated with dental caries, although other bacterial species have these capabilities and thus can also be pathogenic. When environmental factors make it possible to select for these pathogenic bacteria in dental plaque, the disease process begins.

A key environmental factor that allows for selection and proliferation of these pathogenic bacteria is dietary sugar intake. Because these pathogenic bacteria have the ability to ferment sugars, produce acid, and decrease the pH of the dental plaque, they make possible the selection of other aciduric, acidogenic bacteria that will contribute to disease. As more bacteria produce more acid, the pH at the surface of the tooth decreases. This process causes the demineralization of the tooth enamel. Unimpeded, these long periods of low pH and demineralization will result in cavitation.

Saliva is an important factor in buffering the low pH and bringing these demineralization pressures back to a balance with remineralization. In addition to acting as a buffering agent, saliva also flushes the oral cavity of food particles and provides an environment rich in calcium and phosphate to aid in remineralization. When salivary flow is impeded, the pH is able to decrease to a lower level, tipping the scales toward demineralization (disease); in addition, the time it takes to buffer back to a normal pH is longer.

Another important factor that can affect the balance of demineralization and remineralization is fluoride. More in-depth reviews of fluoride are available elsewhere. It is important, however, for pediatricians and other child health care providers to understand how fluoride influences the caries balance. Fluoride has 3 key effects on the caries balance: (1) inhibition of demineralization at the tooth surface; (2) enhancement of remineralization, which results in a more acid-resistant tooth surface; and (3) inhibition of bacterial enzymes. The primary effect of fluoride is topical, via fluoridated toothpastes, mouth rinses, and varnishes, although there is still value in systemic fluoride exposures via fluoridated water and supplements.

Preventive Strategies

Caries Risk Assessment

Ideally, primary prevention efforts will anticipate and prevent caries before the first sign of disease. Preventive strategies for this multifactorial, chronic disease require a comprehensive and multifocal approach that begins with caries risk assessment. Assessing each child’s risk of caries and tailoring preventive strategies to specific risk factors are necessary for maintaining and improving oral health. There is no single test that takes into consideration all risk factors and accurately predicts an individual's susceptibility to caries. However, pediatricians can conduct an excellent risk assessment for caries by focusing on the key risk factors for dental caries that are associated with diet, bacteria, saliva, and status of the teeth (both current status and previous caries experience). The American Academy of Pediatrics (AAP)/Bright Futures Oral Health Risk Assessment Tool can be found at http://www2.aap.org/oralhealth ... html.

Sugars (but not sugar substitutes) are a critical risk factor in the development of caries. The risk of caries is greatest if sugars are consumed at high frequency and are in a form that remains in the mouth for long periods of time. Thus, key behaviors that place a child at high risk of caries include continual bottle/sippy cup use (especially with fluids other than water), sleeping with a bottle (especially with fluids other than water), frequent between-meal snacks of sugars/cooked starch/sugared beverages, and frequent intake of sugared medications.

Early acquisition of S mutans is a major risk factor for early childhood caries and future caries experience. Strong evidence demonstrates that mothers are a primary source of S mutans colonization for their children. Thus, an important factor associated with caries risk in young children is the recent or current presence of active dental decay in the primary caregiver. Prevention, diagnosis, and treatment of oral diseases are highly beneficial, can be undertaken, and should be encouraged during pregnancy with no additional fetal or maternal risk compared with the risk of not providing care. The most important and predictive risk factor for caries, however, is previous caries experience. This finding is not surprising, considering that the factors which initiated the disease process often continue to exist over time.

Other caries risk factors are associated with salivary flow and the status of the teeth. Diseases (eg, diabetes mellitus, Sjögren's syndrome, cystic fibrosis) and medications (eg, antihistamines, anticonvulsants, antidepressants) that result in xerostomia (decreased salivary flow) reduce the availability of saliva to buffer the acid produced by pathogenic bacteria, thus enhancing their ability to cause damage to the teeth. In addition, the teeth of preterm infants, which frequently have enamel defects, are at increased susceptibility for disease. Older children who have deep pits and fissures in their molars are also at increased susceptibility for disease.

Anticipatory Guidance
With a clear understanding of the etiology of dental caries and the risk factors that lead to and facilitate the spread of this disease, pediatricians can target anticipatory guidance to assist families in preventing it. Because the disease of dental caries is multifocal, the anticipatory guidance should also be multifocal. Pediatricians should concentrate their anticipatory guidance on topics that can affect the risk of disease.

Dietary Counseling
Because sugar intake is such an important risk factor for dental caries, pediatricians can incorporate anticipatory guidance associated with preventing dental caries into discussions with families about dietary habits and nutritional intake. Pediatricians should counsel parents and caregivers on the importance of reducing the frequency of exposure to sugars in foods and drinks. To decrease the risk of dental caries and ensure the best possible health and developmental outcomes, pediatricians should recommend that parents do the following:

•Exclusively breastfeed infants for 6 months and continue breastfeeding as complementary foods are introduced for 1 year or longer, as mutually desired by mother and infant.

•Discourage putting a child to bed with a bottle. Establish a bedtime routine conducive to optimal oral health (eg, brush, book, and bed).

•Wean from a bottle by 1 year of age.

•Limit sugary foods and drinks to mealtimes.

•Avoid carbonated, sugared beverages and juice drinks that are not 100% juice.

•Limit the intake of 100% fruit juice to no more than 4 to 6 oz per day.

•Encourage children to drink only water between meals, preferably fluoridated tap water.

•Foster eating patterns that are consistent with guidelines from the US Department of Agriculture.

Oral Hygiene
The value of good oral hygiene lies in controlling the levels and activity of disease-causing bacteria in the oral cavity and delivering fluoride to the surface of the tooth. It is important to remember that pathogenic bacteria can be passed from caregiver to child. Thus, anticipatory guidance for both parent and child is important. Key anticipatory guidance points regarding oral hygiene are as follows:

•Parents/caregivers should be encouraged to model and maintain good oral hygiene and a relationship with their own dental provider.

•Parents/caregivers, especially those with significant history of dental decay, should be cautioned to avoid sharing with their child items that have been in their own mouths.

•The child’s teeth should be brushed twice a day as soon as the teeth erupt with a smear or a grain-of-rice–sized amount of fluoridated toothpaste. After the third birthday, a pea-sized amount should be used.

•Parents/caregivers should help/supervise a child brushing his or her teeth until mastery is obtained, usually at around 8 years of age.

Fluoride
The delivery of fluoride to the teeth includes community-based options (water fluoridation), self-administered modalities (fluoride toothpaste and supplements), and professional applications (fluoride varnish). Each of these delivery mechanisms is useful in preventing dental caries.

Water fluoridation is a community-based intervention that optimizes the level of fluoride in drinking water, resulting in preeruptive and posteruptive protection of the teeth.19 Water fluoridation is a cost-effective means of preventing dental caries, with the lifetime cost per person equaling less than the cost of 1 dental restoration. Most bottled waters do not contain an adequate amount of fluoride.

Fluoride toothpaste is an important way to deliver fluoride to the surface of the tooth. Fluoride toothpaste has been shown to be effective in reducing dental caries in both primary and permanent teeth. It is important to limit the amount of toothpaste used to a smear or a grain-of-rice–sized amount for young children and no more than a pea-sized amount for children older than 3 years. Fluoride supplements should be prescribed for children whose primary source of drinking water is deficient in fluoride.

Fluoride varnish is a professionally applied, sticky resin of highly concentrated fluoride. Two or more applications of fluoride varnish per year are effective in preventing caries in children at high risk of all ages. In most states, pediatricians can apply and be paid for application of fluoride varnish to the teeth of young children. Application of fluoride varnish is even more effective when coupled with counseling. The US Preventive Services Task Force recently published a new recommendation that primary care clinicians apply fluoride varnish to the primary teeth of all infants and children starting at the age of primary tooth eruption (B recommendation). More details and recommendations on fluoride can be found in the AAP clinical report “Fluoride Use in Caries Prevention in the Primary Care Setting.”

Other Important Anticipatory Guidance Topics
A frequent topic of discussion with parents is nonnutritive oral habits, such as use of pacifiers and thumb sucking. AAP policy states that parents consider offering a pacifier at naptime and bedtime because of a protective effect of pacifiers on the incidence of sudden infant death syndrome after the first month of life.27 Both finger- and pacifier-sucking habits will only cause problems with dental structures if they go on for a long period of time. Evaluation by a dentist is indicated for nonnutritive sucking habits that continue beyond 3 years of age.28

Dental injuries are common. Twenty-five percent of all schoolchildren experience some form of dental trauma. Pediatricians can help prevent such trauma by encouraging parents to cover sharp corners of household furnishings at the level of walking toddlers, recommend use of car safety seats, and be aware of electrical cord risk for mouth injury. Pediatricians can also encourage mouthguard use during sports activities in which there is a significant risk of orofacial injury.More information on dental trauma is available in the AAP clinical report “Management of Dental Trauma in a Primary Care Setting.”

Collaboration With Dental Providers
The AAP, the American Academy of Pediatric Dentistry, the American Dental Association, and the American Association of Public Health Dentistry all recommend a dental visit for children by 1 year of age. Although pediatricians have the opportunity to provide early assessment of risk for dental caries and anticipatory guidance to prevent disease, it is also important that children establish a dental home. A dental home is the ongoing relationship between the dentist and the patient, inclusive of all aspects of oral health care delivered in a comprehensive, continuously accessible, coordinated, and family-centered way.

Unfortunately, little is known about pediatric health care providers’ dental referral behaviors and patterns. Although 1 study found that children 2 to 5 years of age who received a recommendation from their health care provider to visit the dentist were more likely to have a dental visit, the US Preventive Services Task Force found no study that evaluated the effects of referral by a primary care clinician to a dentist on caries incidence. It is also noteworthy that preschool-aged children covered by Medicaid who had an early preventive dental visit by 1 year of age were more likely to use subsequent preventive services and to have lower dental expenses.

With early referral to a dental provider, there is an opportunity to maintain good oral health, prevent disease, and treat disease early. Establishing such collaborative relationships between physicians and dentists at the community level is essential for increasing access to dental care for all children and improving their oral and overall health.

Conclusions
Oral health is an integral part of the overall health and well-being of children. A pediatrician who is familiar with the science of dental caries, capable of assessing caries risk, comfortable with applying various strategies of prevention and intervention, and connected to dental resources can contribute considerably to the health of his or her patients. This policy statement, in conjunction with the oral health recommendations of the third edition of the AAP's Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, serves as a resource for pediatricians and other pediatric primary care providers to be knowledgeable about addressing dental caries. Because dental caries is such a common and consequential disease process in the pediatric population, it is essential that pediatricians include oral health in their daily practice of pediatrics.

Suggestions for Pediatricians

1.Administer an oral health risk assessment periodically to all children.

2.Include anticipatory guidance for oral health as an integral part of comprehensive patient counseling.

3.Counsel parents/caregivers and patients to reduce the frequency of exposure to sugars in foods and drinks.

4.Encourage parents/caregivers to brush a child’s teeth as soon as teeth erupt with a smear or a grain-of-rice–sized amount of fluoride toothpaste and a pea-sized amount at 3 years of age.

5.Advise parents/caregivers to monitor brushing until 8 years of age.

6.Refer to the AAP clinical report, “Fluoride Use in Caries Prevention in the Primary Care Setting,” for fluoride administration and supplementation decisions.

Today’s children and adolescents are immersed in both traditional and new forms of digital media. Research on traditional media, such as television, has identified health concerns and negative outcomes that correlate with the duration and content of viewing. Over the past decade, the use of digital media, including interactive and social media, has grown, and research evidence suggests that these newer media offer both benefits and risks to the health of children and teenagers. Evidence-based benefits identified from the use of digital and social media include early learning, exposure to new ideas and knowledge, increased opportunities for social contact and support, and new opportunities to access health promotion messages and information. Risks of such media include negative health effects on sleep, attention, and learning; a higher incidence of obesity and depression; exposure to inaccurate, inappropriate, or unsafe content and contacts; and compromised privacy and confidentiality. This technical report reviews the literature regarding these opportunities and risks, framed around clinical questions, for children from birth to adulthood. To promote health and wellness in children and adolescents, it is important to maintain adequate physical activity, healthy nutrition, good sleep hygiene, and a nurturing social environment. A healthy Family Media Use Plan (www.healthychildren.org/MediaUsePlan) that is individualized for a specific child, teenager, or family can identify an appropriate balance between screen time/online time and other activities, set boundaries for accessing content, guide displays of personal information, encourage age-appropriate critical thinking and digital literacy, and support open family communication and implementation of consistent rules about media use.

Introduction

Today’s generation of children and adolescents are growing up immersed in media, including broadcast and social media. Broadcast media include television and movies. Interactive media include social media and video games in which users can both consume and create content. Interactive media allow information sharing and provide an engaging digital environment that becomes highly personalized.

Media Use Patterns

The most common broadcast medium continues to be TV. A recent study found that TV hours among school-aged children have decreased in the past decade for children younger than 8 years.1 However, among children aged 8 years and older, average daily TV time remains over 2 hours per day.2 TV viewing also has changed over the past decade, with content available via streaming or social media sites, such as YouTube and Netflix.

Overall media use among adolescents has continued to grow over the past decade, aided by the recent increase in mobile phone use among teenagers. Approximately three-quarters of teenagers today own a smartphone,3 which allows access to the Internet, streaming TV/videos, and interactive “apps.” Approximately one-quarter of teenagers describe themselves as “constantly connected” to the Internet.

Social media sites and mobile apps provide platforms for users to create an online identity, communicate with others, and build social networks. At present, 76% of teenagers use at least 1 social media site. Although Facebook remains the most popular social media site,3 teenagers do not typically commit to just 1 social media platform; more than 70% maintain a “social media portfolio” of several selected sites, including Facebook, Twitter, and Instagram.3 Mobile apps provide a breadth of functions, such as photo sharing, games, and video-chatting.

Video games remain very popular among families; 4 of 5 households own a device used to play video games.Boys are the most avid video game players, with 91% of boys reporting having access to a game console and 84% reporting playing video games online or on a cell phone.

Benefits of Media

Both traditional and social media can provide exposure to new ideas and information, raising awareness of current events and issues. Interactive media also can provide opportunities for the promotion of community participation and civic engagement. Students can collaborate with others on assignments and projects on many online media platforms. The use of social media helps families and friends who are separated geographically communicate across the miles.

Social media can enhance access to valuable support networks, which may be particularly helpful for patients with ongoing illnesses, conditions, or disabilities.In 1 study, young adults described the benefits of seeking health information online and through social media, and recognized these channels as useful supplementary sources of information to health care visits.6 Research also supports the use of social media to foster social inclusion among users who may feel excluded or who are seeking a welcoming community: for example, those identifying as lesbian, gay, bisexual, transgender, questioning, or intersex. Finally, social media may be used to enhance wellness and promote healthy behaviors, such as smoking cessation and balanced nutrition.

Risks of Media

A first area of health concern is media use and obesity, and most studies have focused on TV. One study found that the odds of being overweight were almost 5 times greater for adolescents who watch more than 5 hours of TV per day compared with those who watch 0 to 2 hours.9 This study’s findings contributed to recommendations by the American Academy of Pediatrics that children have 2 hours or less of sedentary screen time daily. More recent studies have provided new evidence that watching TV for more than 1.5 hours daily was a risk factor for obesity, but only for children 4 through 9 years of age.10 Increased caloric intake via snacking while watching TV has been shown to be a risk factor for obesity, as is exposure to advertising for high-calorie foods and snacks.Having a TV in the bedroom continues to be associated with the risk of obesity.

Evidence suggests that media use can negatively affect sleep.Studies show that those with higher social media use15 or who sleep with mobile devices in their roomswere at greater risk of sleep disturbances. Exposure to light (particularly blue light) and activity from screens before bed affects melatonin levels and can delay or disrupt sleep.Media use around or after bedtime can disrupt sleep and negatively affect school performance.

Children who overuse online media are at risk of problematic Internet use, and heavy users of video games are at risk of Internet gaming disorder. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition,lists both as conditions in need of further research. Symptoms can include a preoccupation with the activity, decreased interest in offline or “real life” relationships, unsuccessful attempts to decrease use, and withdrawal symptoms. The prevalence of problematic Internet use among children and adolescents is between 4% and 8%,21,22 and up to 8.5% of US youth 8 to 18 years of age meet criteria for Internet gaming disorder.

At home, many children and teenagers use entertainment media at the same time that they are engaged in other tasks, such as homework.A growing body of evidence suggests that the use of media while engaged in academic tasks has negative consequences on learning.

Media Influence

Evidence gathered over decades supports links between media exposure and health behaviors among teenagers.The exposure of adolescents through media to alcohol,28,29 tobacco use,30,31 or sexual behaviors is associated with earlier initiation of these behaviors.

Adolescents’ displays on social media frequently include portrayal of health risk behaviors, such as substance use, sexual behaviors, self-injury, or disordered eating.Peer viewers of such content may see these behaviors as normative and desirable.Research from both the United States and the United Kingdom indicates that the major alcohol brands maintain a strong presence on Facebook, Twitter, and YouTube.

Cyberbullying, Sexting, and Online Solicitation

Cyberbullying and traditional bullying overlap, although online bullying presents unique challenges. These challenges include that perpetrators can be anonymous and bully at any time of day, that information can spread online rapidly, and that perpetrator and target roles can be quite fluid in the online world. Cyberbullying can lead to short- and long-term negative social, academic, and health consequences for both the perpetrator and the target. Fortunately, newer studies suggest that interventions that target bullying may reduce cyberbullying.

“Sexting” is commonly defined as the electronic transmission of nude or seminude images as well as sexually explicit text messages. It is estimated that ∼12% of youth aged 10 to 19 years have ever sent a sexual photo to someone else. The Internet also has created opportunities for the exploitation of children by sex offenders through social networking, chat rooms, e-mail, and online games.

Social Media and Mental Health

Research studies have identified both benefits and concerns regarding mental health and social media use. Benefits from the use of social media in moderation include the opportunity for enhanced social support and connection. Research has suggested a U-shaped relationship between Internet use and depression, with increased risks of depression at both the high and low ends of Internet use. One study found that older adolescents who used social media passively (eg, viewing others’ photos) reported declines in life satisfaction, whereas those who interacted with others and posted content did not experience these declines.Thus, in addition to the number of hours an individual spends on social media, a key factor is how social media is used.

Social Media and Privacy

Content that an adolescent chooses to post is shared with others, and the removal of such content once posted may be difficult or impossible. Adolescents vary in their understanding of privacy practices; even those who know how to set privacy settings often don’t believe they will work.Despite efforts by some social media sites to protect privacy or to delete content after it is viewed, privacy violations and unwelcome distribution are always risks.

Parent Media Use and Child Health

Social media can provide positive social experiences, such as opportunities for parents to connect with children via video-chat services. Unfortunately, some parents can be distracted by media and miss important opportunities for emotional connections that are known to improve child health.53,54 One research study found that when a parent turned his or her attention to a mobile device while with a young child, the parent was less likely to talk with the child.Parental engagement is critical in the development of children’s emotional and social development, and these distractions may have short- and long-term negative effects.

Conclusions

The effects of media use are multifactorial and depend on the type of media, the type of use, the amount and extent of use, and the characteristics of the individual child. Children today are growing up in an era of highly personalized media use experiences, so parents must develop personalized media use plans for their children that attend to each child’s age, health, temperament, and developmental stage. Research evidence shows that children and teenagers need adequate sleep, physical activity, and time away from media. Pediatricians can help families develop a Family Media Use Plan (www.HealthyChildren.org/MediaUsePlan) that prioritizes these and other health goals.

Recommendations

Pediatricians

Work with families and schools to promote understanding of the benefits and risks of media.

Promote adherence to guidelines for adequate physical activity and sleep via a Family Media Use Plan (www.HealthyChildren.org/MediaUsePlan).

Advocate for and promote information and training in media literacy.

Be aware of tools to screen for sexting, cyberbullying, problematic Internet use, and Internet gaming disorder.

Families

Develop, consistently follow, and routinely revisit a Family Media Use plan (see the plan from the American Academy of Pediatrics at www.HealthyChildren.org/MediaUsePlan).

Address what type of and how much media are used and what media behaviors are appropriate for each child or teenager, and for parents. Place consistent limits on hours per day of media use as well as types of media used.

Promote that children and adolescents get the recommended amount of daily physical activity (1 hour) and adequate sleep (8–12 hours, depending on age).

Recommend that children not sleep with devices in their bedrooms, including TVs, computers, and smartphones. Avoid exposure to devices or screens for 1 hour before bedtime.

Discourage entertainment media while doing homework.

Designate media-free times together (eg, family dinner) and media-free locations (eg, bedrooms) in homes. Promote activities that are likely to facilitate development and health, including positive parenting activities, such as reading, teaching, talking, and playing together.

Communicate guidelines to other caregivers, such as babysitters or grandparents, so that media rules are followed consistently.

Engage in selecting and co-viewing media with your child, through which your child can use media to learn and be creative, and share these experiences with your family and your community.

Have ongoing communication with children about online citizenship and safety, including treating others with respect online and offline, avoiding cyberbullying and sexting, being wary of online solicitation, and avoiding communications that can compromise personal privacy and safety.

Actively develop a network of trusted adults (eg, aunts, uncles, coaches, etc) who can engage with children through social media and to whom children can turn when they encounter challenges.

Researchers, Governmental Organizations, and Industry

Continue research into the risks and benefits of media.

Prioritize longitudinal and robust study designs, including new methodologies for understanding media exposure and use.

Today’s children and adolescents are immersed in both traditional and new forms of digital media. Research on traditional media, such as television, has identified health concerns and negative outcomes that correlate with the duration and content of viewing. Over the past decade, the use of digital media, including interactive and social media, has grown, and research evidence suggests that these newer media offer both benefits and risks to the health of children and teenagers. Evidence-based benefits identified from the use of digital and social media include early learning, exposure to new ideas and knowledge, increased opportunities for social contact and support, and new opportunities to access health promotion messages and information. Risks of such media include negative health effects on sleep, attention, and learning; a higher incidence of obesity and depression; exposure to inaccurate, inappropriate, or unsafe content and contacts; and compromised privacy and confidentiality. This technical report reviews the literature regarding these opportunities and risks, framed around clinical questions, for children from birth to adulthood. To promote health and wellness in children and adolescents, it is important to maintain adequate physical activity, healthy nutrition, good sleep hygiene, and a nurturing social environment. A healthy Family Media Use Plan (www.healthychildren.org/MediaUsePlan) that is individualized for a specific child, teenager, or family can identify an appropriate balance between screen time/online time and other activities, set boundaries for accessing content, guide displays of personal information, encourage age-appropriate critical thinking and digital literacy, and support open family communication and implementation of consistent rules about media use.

Introduction

Today’s generation of children and adolescents are growing up immersed in media, including broadcast and social media. Broadcast media include television and movies. Interactive media include social media and video games in which users can both consume and create content. Interactive media allow information sharing and provide an engaging digital environment that becomes highly personalized.

Media Use Patterns

The most common broadcast medium continues to be TV. A recent study found that TV hours among school-aged children have decreased in the past decade for children younger than 8 years.1 However, among children aged 8 years and older, average daily TV time remains over 2 hours per day.2 TV viewing also has changed over the past decade, with content available via streaming or social media sites, such as YouTube and Netflix.

Overall media use among adolescents has continued to grow over the past decade, aided by the recent increase in mobile phone use among teenagers. Approximately three-quarters of teenagers today own a smartphone,3 which allows access to the Internet, streaming TV/videos, and interactive “apps.” Approximately one-quarter of teenagers describe themselves as “constantly connected” to the Internet.

Social media sites and mobile apps provide platforms for users to create an online identity, communicate with others, and build social networks. At present, 76% of teenagers use at least 1 social media site. Although Facebook remains the most popular social media site,3 teenagers do not typically commit to just 1 social media platform; more than 70% maintain a “social media portfolio” of several selected sites, including Facebook, Twitter, and Instagram.3 Mobile apps provide a breadth of functions, such as photo sharing, games, and video-chatting.

Video games remain very popular among families; 4 of 5 households own a device used to play video games.Boys are the most avid video game players, with 91% of boys reporting having access to a game console and 84% reporting playing video games online or on a cell phone.

Benefits of Media

Both traditional and social media can provide exposure to new ideas and information, raising awareness of current events and issues. Interactive media also can provide opportunities for the promotion of community participation and civic engagement. Students can collaborate with others on assignments and projects on many online media platforms. The use of social media helps families and friends who are separated geographically communicate across the miles.

Social media can enhance access to valuable support networks, which may be particularly helpful for patients with ongoing illnesses, conditions, or disabilities.In 1 study, young adults described the benefits of seeking health information online and through social media, and recognized these channels as useful supplementary sources of information to health care visits.6 Research also supports the use of social media to foster social inclusion among users who may feel excluded or who are seeking a welcoming community: for example, those identifying as lesbian, gay, bisexual, transgender, questioning, or intersex. Finally, social media may be used to enhance wellness and promote healthy behaviors, such as smoking cessation and balanced nutrition.

Risks of Media

A first area of health concern is media use and obesity, and most studies have focused on TV. One study found that the odds of being overweight were almost 5 times greater for adolescents who watch more than 5 hours of TV per day compared with those who watch 0 to 2 hours.9 This study’s findings contributed to recommendations by the American Academy of Pediatrics that children have 2 hours or less of sedentary screen time daily. More recent studies have provided new evidence that watching TV for more than 1.5 hours daily was a risk factor for obesity, but only for children 4 through 9 years of age.10 Increased caloric intake via snacking while watching TV has been shown to be a risk factor for obesity, as is exposure to advertising for high-calorie foods and snacks.Having a TV in the bedroom continues to be associated with the risk of obesity.

Evidence suggests that media use can negatively affect sleep.Studies show that those with higher social media use15 or who sleep with mobile devices in their roomswere at greater risk of sleep disturbances. Exposure to light (particularly blue light) and activity from screens before bed affects melatonin levels and can delay or disrupt sleep.Media use around or after bedtime can disrupt sleep and negatively affect school performance.

Children who overuse online media are at risk of problematic Internet use, and heavy users of video games are at risk of Internet gaming disorder. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition,lists both as conditions in need of further research. Symptoms can include a preoccupation with the activity, decreased interest in offline or “real life” relationships, unsuccessful attempts to decrease use, and withdrawal symptoms. The prevalence of problematic Internet use among children and adolescents is between 4% and 8%,21,22 and up to 8.5% of US youth 8 to 18 years of age meet criteria for Internet gaming disorder.

At home, many children and teenagers use entertainment media at the same time that they are engaged in other tasks, such as homework.A growing body of evidence suggests that the use of media while engaged in academic tasks has negative consequences on learning.

Media Influence

Evidence gathered over decades supports links between media exposure and health behaviors among teenagers.The exposure of adolescents through media to alcohol,28,29 tobacco use,30,31 or sexual behaviors is associated with earlier initiation of these behaviors.

Adolescents’ displays on social media frequently include portrayal of health risk behaviors, such as substance use, sexual behaviors, self-injury, or disordered eating.Peer viewers of such content may see these behaviors as normative and desirable.Research from both the United States and the United Kingdom indicates that the major alcohol brands maintain a strong presence on Facebook, Twitter, and YouTube.

Cyberbullying, Sexting, and Online Solicitation

Cyberbullying and traditional bullying overlap, although online bullying presents unique challenges. These challenges include that perpetrators can be anonymous and bully at any time of day, that information can spread online rapidly, and that perpetrator and target roles can be quite fluid in the online world. Cyberbullying can lead to short- and long-term negative social, academic, and health consequences for both the perpetrator and the target. Fortunately, newer studies suggest that interventions that target bullying may reduce cyberbullying.

“Sexting” is commonly defined as the electronic transmission of nude or seminude images as well as sexually explicit text messages. It is estimated that ∼12% of youth aged 10 to 19 years have ever sent a sexual photo to someone else. The Internet also has created opportunities for the exploitation of children by sex offenders through social networking, chat rooms, e-mail, and online games.

Social Media and Mental Health

Research studies have identified both benefits and concerns regarding mental health and social media use. Benefits from the use of social media in moderation include the opportunity for enhanced social support and connection. Research has suggested a U-shaped relationship between Internet use and depression, with increased risks of depression at both the high and low ends of Internet use. One study found that older adolescents who used social media passively (eg, viewing others’ photos) reported declines in life satisfaction, whereas those who interacted with others and posted content did not experience these declines.Thus, in addition to the number of hours an individual spends on social media, a key factor is how social media is used.

Social Media and Privacy

Content that an adolescent chooses to post is shared with others, and the removal of such content once posted may be difficult or impossible. Adolescents vary in their understanding of privacy practices; even those who know how to set privacy settings often don’t believe they will work.Despite efforts by some social media sites to protect privacy or to delete content after it is viewed, privacy violations and unwelcome distribution are always risks.

Parent Media Use and Child Health

Social media can provide positive social experiences, such as opportunities for parents to connect with children via video-chat services. Unfortunately, some parents can be distracted by media and miss important opportunities for emotional connections that are known to improve child health.53,54 One research study found that when a parent turned his or her attention to a mobile device while with a young child, the parent was less likely to talk with the child.Parental engagement is critical in the development of children’s emotional and social development, and these distractions may have short- and long-term negative effects.

Conclusions

The effects of media use are multifactorial and depend on the type of media, the type of use, the amount and extent of use, and the characteristics of the individual child. Children today are growing up in an era of highly personalized media use experiences, so parents must develop personalized media use plans for their children that attend to each child’s age, health, temperament, and developmental stage. Research evidence shows that children and teenagers need adequate sleep, physical activity, and time away from media. Pediatricians can help families develop a Family Media Use Plan (www.HealthyChildren.org/MediaUsePlan) that prioritizes these and other health goals.

Recommendations

Pediatricians

Work with families and schools to promote understanding of the benefits and risks of media.

Promote adherence to guidelines for adequate physical activity and sleep via a Family Media Use Plan (www.HealthyChildren.org/MediaUsePlan).

Advocate for and promote information and training in media literacy.

Be aware of tools to screen for sexting, cyberbullying, problematic Internet use, and Internet gaming disorder.

Families

Develop, consistently follow, and routinely revisit a Family Media Use plan (see the plan from the American Academy of Pediatrics at www.HealthyChildren.org/MediaUsePlan).

Address what type of and how much media are used and what media behaviors are appropriate for each child or teenager, and for parents. Place consistent limits on hours per day of media use as well as types of media used.

Promote that children and adolescents get the recommended amount of daily physical activity (1 hour) and adequate sleep (8–12 hours, depending on age).

Recommend that children not sleep with devices in their bedrooms, including TVs, computers, and smartphones. Avoid exposure to devices or screens for 1 hour before bedtime.

Discourage entertainment media while doing homework.

Designate media-free times together (eg, family dinner) and media-free locations (eg, bedrooms) in homes. Promote activities that are likely to facilitate development and health, including positive parenting activities, such as reading, teaching, talking, and playing together.

Communicate guidelines to other caregivers, such as babysitters or grandparents, so that media rules are followed consistently.

Engage in selecting and co-viewing media with your child, through which your child can use media to learn and be creative, and share these experiences with your family and your community.

Have ongoing communication with children about online citizenship and safety, including treating others with respect online and offline, avoiding cyberbullying and sexting, being wary of online solicitation, and avoiding communications that can compromise personal privacy and safety.

Actively develop a network of trusted adults (eg, aunts, uncles, coaches, etc) who can engage with children through social media and to whom children can turn when they encounter challenges.

Researchers, Governmental Organizations, and Industry

Continue research into the risks and benefits of media.

Prioritize longitudinal and robust study designs, including new methodologies for understanding media exposure and use.

Infants, toddlers, and preschoolers are now growing up in environments saturated with a variety of traditional and new technologies, which they are adopting at increasing rates. Although there has been much hope for the educational potential of interactive media for young children, accompanied by fears about their overuse during this crucial period of rapid brain development, research in this area still remains limited. This policy statement reviews the existing literature on television, videos, and mobile/interactive technologies; their potential for educational benefit; and related health concerns for young children (0 to 5 years of age). The statement also highlights areas in which pediatric providers can offer specific guidance to families in managing their young children’s media use, not only in terms of content or time limits, but also emphasizing the importance of parent–child shared media use and allowing the child time to take part in other developmentally healthy activities.

Introduction

Technologic innovation has transformed media and its role in the lives of infants and young children. More children, even in economically challenged households, are using newer digital technologies, such as interactive and mobile media, on a daily basis1 and continue to be the target of intense marketing. This policy statement addresses the influence of media on the health and development of children from 0 to 5 years of age, a time of critical brain development, building secure relationships, and establishing health behaviors.

Infants and Toddlers

Children younger than 2 years need hands-on exploration and social interaction with trusted caregivers to develop their cognitive, language, motor, and social-emotional skills. Because of their immature symbolic, memory, and attentional skills, infants and toddlers cannot learn from traditional digital media as they do from interactions with caregivers,and they have difficulty transferring that knowledge to their 3-dimensional experience.The chief factor that facilitates toddlers’ learning from commercial media (starting around 15 months of age) is parents watching with them and reteaching the content.

The interactivity of touchscreens enables applications (apps) to identify when a child responds accurately and then tailor its responses, thereby supporting children at their levels of competence. Emerging evidence shows that at 24 months of age, children can learn words from live video-chatting with a responsive adult or from an interactive touchscreen interface that scaffolds the child to choose the relevant answers. Starting at 15 months of age, toddlers can learn novel words from touchscreens in laboratory-based studies but have trouble transferring this knowledge to the 3-dimensional world. However, it should be noted that these experiments used specially designed apps that are not commercially available.

Many parents now use video-chat (eg, Skype, FaceTime) as an interactive media form that facilitates social connection with distant relatives. New evidence shows that infants and toddlers regularly engage in video-chatting, but the same principles regarding need for parental support would apply in order for infants and toddlers to understand what they are seeing.

In summary, for children younger than 2 years, evidence for benefits of media is still limited, adult interaction with the child during media use is crucial, and there continues to be evidence of harm from excessive digital media use, as described later in this statement.

Preschool Media and Learning

Well-designed television programs, such as Sesame Street, can improve cognitive, literacy, and social outcomes for children 3 to 5 years of age and continue to create programming that addresses evolving child health and developmental needs (eg, obesity prevention, resilience). Evaluations of apps from Sesame Workshop and the Public Broadcasting Service (PBS) also have shown efficacy in teaching literacy skills to preschoolers.Unfortunately, most apps parents find under the “educational” category in app stores have no such evidence of efficacy, target only rote academic skills, are not based on established curricula, and use little or no input from developmental specialists or educators. Most apps also generally are not designed for a dual audience (ie, both parent and child). It is important to emphasize to parents that the higher-order thinking skills and executive functions essential for school success, such as task persistence, impulse control, emotion regulation, and creative, flexible thinking, are best taught through unstructured and social (not digital) play,as well as responsive parent–child interactions.

Digital books (also called “eBooks,” books that can be read on a screen) often come with interactive enhancements that, research suggests, may decrease child comprehension of content or parent dialogic reading interactions when visual effects are distracting.Parents should, therefore, be instructed to interact with children during eBook reading, as they would a print book.

Health and Developmental Concerns

Obesity

Heavy media use during preschool years is associated with small but significant increases in BMI,18 may explain disparities in obesity risk in minority children,19 and sets the stage for weight gain later in childhood.Although many studies have used a 2-hour cutoff to examine obesity risk, a recent study of 2-year-olds found that BMI increased for every hour per week of media consumed.It is believed that exposure to food advertising and watching television while eating (which diminishes attention to satiety cues) drives these associations.

Sleep

Increased duration of media exposure and the presence of a television, computer, or mobile device in the bedroom in early childhood have been associated with fewer minutes of sleep per night.

Even infants exposed to screen media in the evening hours show significantly shorter night-time sleep duration than those with no evening screen exposure. Mechanisms underlying this association include arousing content and suppression of endogenous melatonin by blue light emitted from screens.

Child Development

Population-based studies continue to show associations between excessive television viewing in early childhood and cognitive,language,and social/emotional delays, likely secondary to decreases in parent–child interaction when the television is on37 and poorer family functioning in households with high media use. An earlier age of media use onset, greater cumulative hours of media use, and non-PBS content all are significant independent predictors of poor executive functioning in preschoolers.Content is crucial: experimental evidence shows that switching from violent content to educational/prosocial content results in significant improvement in behavioral symptoms, particularly for low-income boys.Notably, the quality of parenting can modify associations between media use and child development: one study found that inappropriate content and inconsistent parenting had cumulative negative effects on low-income preschoolers’ executive function, whereas warm parenting and educational content interacted to produce additive benefits.

Child characteristics also may influence how much media children consume: excessive television viewing is more likely in infants and toddlers with a difficult temperamentor self-regulation problems, and toddlers with social-emotional delays are more likely to be given a mobile device to calm them down.

Parental Media Use

Parents’ background television use distracts from parent–child interactions and child play.Heavy parent use of mobile devices is associated with fewer verbal and nonverbal interactions between parents and children and may be associated with more parent-child conflict. Because parent media use is a strong predictor of child media habits,reducing parental media use and enhancing parent–child interactions may be an important area of behavior change.

Conclusions: Clinical Implications

In summary, multiple developmental and health concerns continue to exist for young children using all forms of digital media to excess. Evidence is sufficient to recommend time limitations on digital media use for children 2 to 5 years to no more than 1 hour per day to allow children ample time to engage in other activities important to their health and development and to establish media viewing habits associated with lower risk of obesity later in life.In addition, encouraging parents to change to educational and prosocial content and engage with their children around technology will allow children to reap the most benefit from what they view.

As digital technologies become more ubiquitous, pediatric providers must guide parents not only on the duration and content of media their child uses, but also on (1) creating unplugged spaces and times in their homes, because devices can now be taken anywhere; (2) the ability of new technologies to be used in social and creative ways; and (3) the importance of not displacing sleep, exercise, play, reading aloud, and social interactions. Realistically, pediatric providers will need to know how to help parents find resources finding appropriate content, tools for monitoring or limiting child use, ideas for play or activities in which to engage rather than digital play, and how parents can limit their own media use (see HealthyChildren.org for examples); each of these can be built into the Family Media Use Plan (see the American Academy of Pediatrics guide to developing a plan at www.healthychildren.org/MediaUsePlan).

Recommendations

Pediatricians

Start the conversation early. Ask parents of infants and young children about family media use, their children’s use habits, and media use locations.

Help families develop a Family Media Use Plan (www.healthychildren.org/MediaUsePlan) with specific guidelines for each child and parent.

Educate parents about brain development in the early years and the importance of hands-on, unstructured, and social play to build language, cognitive, and social-emotional skills.

For children younger than 18 months, discourage use of screen media other than video-chatting.

For parents of children 18 to 24 months of age who want to introduce digital media, advise that they choose high-quality programming/apps and use them together with children, because this is how toddlers learn best. Letting children use media by themselves should be avoided.

In children older than 2 years, limit media to 1 hour or less per day of high-quality programming. Recommend shared use between parent and child to promote enhanced learning, greater interaction, and limit setting.

Avoid digital media use (except video-chatting) in children younger than 18 to 24 months.

For children ages 18 to 24 months of age, if you want to introduce digital media, choose high-quality programming and use media together with your child. Avoid solo media use in this age group.

Do not feel pressured to introduce technology early; interfaces are so intuitive that children will figure them out quickly once they start using them at home or in school.

For children 2 to 5 years of age, limit screen use to 1 hour per day of high-quality programming, coview with your children, help children understand what they are seeing, and help them apply what they learn to the world around them.

Avoid fast-paced programs (young children do not understand them as well), apps with lots of distracting content, and any violent content.

Turn off televisions and other devices when not in use.

Avoid using media as the only way to calm your child. Although there are intermittent times (eg, medical procedures, airplane flights) when media is useful as a soothing strategy, there is concern that using media as strategy to calm could lead to problems with limit setting or the inability of children to develop their own emotion regulation. Ask your pediatrician for help if needed.

Monitor children’s media content and what apps are used or downloaded. Test apps before the child uses them, play together, and ask the child what he or she thinks about the app.

Keep bedrooms, mealtimes, and parent–child playtimes screen free for children and parents. Parents can set a “do not disturb” option on their phones during these times.

No screens 1 hour before bedtime, and remove devices from bedrooms before bed.

Consult the American Academy of Pediatrics Family Media Use Plan, available at: www.healthychildren.org/MediaUsePlan.

Industry

Work with developmental psychologists and educators to create design interfaces that are appropriate to child developmental abilities, that are not distracting, and that promote shared parent–child media use and application of skills to the real world. Cease making apps for children younger than 18 months until evidence of benefit is demonstrated.

Formally and scientifically evaluate products before making educational claims.

Make high-quality products accessible and affordable to low-income families and in multiple languages.

Eliminate advertising and unhealthy messages on apps. Children at this age cannot differentiate between advertisements and factual information, and therefore, advertising to them is unethical.

Help parents to set limits by stopping auto-advance of videos as the default setting. Develop systems embedded in devices that can help parents monitor and limit media use.

Infants, toddlers, and preschoolers are now growing up in environments saturated with a variety of traditional and new technologies, which they are adopting at increasing rates. Although there has been much hope for the educational potential of interactive media for young children, accompanied by fears about their overuse during this crucial period of rapid brain development, research in this area still remains limited. This policy statement reviews the existing literature on television, videos, and mobile/interactive technologies; their potential for educational benefit; and related health concerns for young children (0 to 5 years of age). The statement also highlights areas in which pediatric providers can offer specific guidance to families in managing their young children’s media use, not only in terms of content or time limits, but also emphasizing the importance of parent–child shared media use and allowing the child time to take part in other developmentally healthy activities.

Introduction

Technologic innovation has transformed media and its role in the lives of infants and young children. More children, even in economically challenged households, are using newer digital technologies, such as interactive and mobile media, on a daily basis1 and continue to be the target of intense marketing. This policy statement addresses the influence of media on the health and development of children from 0 to 5 years of age, a time of critical brain development, building secure relationships, and establishing health behaviors.

Infants and Toddlers

Children younger than 2 years need hands-on exploration and social interaction with trusted caregivers to develop their cognitive, language, motor, and social-emotional skills. Because of their immature symbolic, memory, and attentional skills, infants and toddlers cannot learn from traditional digital media as they do from interactions with caregivers,and they have difficulty transferring that knowledge to their 3-dimensional experience.The chief factor that facilitates toddlers’ learning from commercial media (starting around 15 months of age) is parents watching with them and reteaching the content.

The interactivity of touchscreens enables applications (apps) to identify when a child responds accurately and then tailor its responses, thereby supporting children at their levels of competence. Emerging evidence shows that at 24 months of age, children can learn words from live video-chatting with a responsive adult or from an interactive touchscreen interface that scaffolds the child to choose the relevant answers. Starting at 15 months of age, toddlers can learn novel words from touchscreens in laboratory-based studies but have trouble transferring this knowledge to the 3-dimensional world. However, it should be noted that these experiments used specially designed apps that are not commercially available.

Many parents now use video-chat (eg, Skype, FaceTime) as an interactive media form that facilitates social connection with distant relatives. New evidence shows that infants and toddlers regularly engage in video-chatting, but the same principles regarding need for parental support would apply in order for infants and toddlers to understand what they are seeing.

In summary, for children younger than 2 years, evidence for benefits of media is still limited, adult interaction with the child during media use is crucial, and there continues to be evidence of harm from excessive digital media use, as described later in this statement.

Preschool Media and Learning

Well-designed television programs, such as Sesame Street, can improve cognitive, literacy, and social outcomes for children 3 to 5 years of age and continue to create programming that addresses evolving child health and developmental needs (eg, obesity prevention, resilience). Evaluations of apps from Sesame Workshop and the Public Broadcasting Service (PBS) also have shown efficacy in teaching literacy skills to preschoolers.Unfortunately, most apps parents find under the “educational” category in app stores have no such evidence of efficacy, target only rote academic skills, are not based on established curricula, and use little or no input from developmental specialists or educators. Most apps also generally are not designed for a dual audience (ie, both parent and child). It is important to emphasize to parents that the higher-order thinking skills and executive functions essential for school success, such as task persistence, impulse control, emotion regulation, and creative, flexible thinking, are best taught through unstructured and social (not digital) play,as well as responsive parent–child interactions.

Digital books (also called “eBooks,” books that can be read on a screen) often come with interactive enhancements that, research suggests, may decrease child comprehension of content or parent dialogic reading interactions when visual effects are distracting.Parents should, therefore, be instructed to interact with children during eBook reading, as they would a print book.

Health and Developmental Concerns

Obesity

Heavy media use during preschool years is associated with small but significant increases in BMI,18 may explain disparities in obesity risk in minority children,19 and sets the stage for weight gain later in childhood.Although many studies have used a 2-hour cutoff to examine obesity risk, a recent study of 2-year-olds found that BMI increased for every hour per week of media consumed.It is believed that exposure to food advertising and watching television while eating (which diminishes attention to satiety cues) drives these associations.

Sleep

Increased duration of media exposure and the presence of a television, computer, or mobile device in the bedroom in early childhood have been associated with fewer minutes of sleep per night.

Even infants exposed to screen media in the evening hours show significantly shorter night-time sleep duration than those with no evening screen exposure. Mechanisms underlying this association include arousing content and suppression of endogenous melatonin by blue light emitted from screens.

Child Development

Population-based studies continue to show associations between excessive television viewing in early childhood and cognitive,language,and social/emotional delays, likely secondary to decreases in parent–child interaction when the television is on37 and poorer family functioning in households with high media use. An earlier age of media use onset, greater cumulative hours of media use, and non-PBS content all are significant independent predictors of poor executive functioning in preschoolers.Content is crucial: experimental evidence shows that switching from violent content to educational/prosocial content results in significant improvement in behavioral symptoms, particularly for low-income boys.Notably, the quality of parenting can modify associations between media use and child development: one study found that inappropriate content and inconsistent parenting had cumulative negative effects on low-income preschoolers’ executive function, whereas warm parenting and educational content interacted to produce additive benefits.

Child characteristics also may influence how much media children consume: excessive television viewing is more likely in infants and toddlers with a difficult temperamentor self-regulation problems, and toddlers with social-emotional delays are more likely to be given a mobile device to calm them down.

Parental Media Use

Parents’ background television use distracts from parent–child interactions and child play.Heavy parent use of mobile devices is associated with fewer verbal and nonverbal interactions between parents and children and may be associated with more parent-child conflict. Because parent media use is a strong predictor of child media habits,reducing parental media use and enhancing parent–child interactions may be an important area of behavior change.

Conclusions: Clinical Implications

In summary, multiple developmental and health concerns continue to exist for young children using all forms of digital media to excess. Evidence is sufficient to recommend time limitations on digital media use for children 2 to 5 years to no more than 1 hour per day to allow children ample time to engage in other activities important to their health and development and to establish media viewing habits associated with lower risk of obesity later in life.In addition, encouraging parents to change to educational and prosocial content and engage with their children around technology will allow children to reap the most benefit from what they view.

As digital technologies become more ubiquitous, pediatric providers must guide parents not only on the duration and content of media their child uses, but also on (1) creating unplugged spaces and times in their homes, because devices can now be taken anywhere; (2) the ability of new technologies to be used in social and creative ways; and (3) the importance of not displacing sleep, exercise, play, reading aloud, and social interactions. Realistically, pediatric providers will need to know how to help parents find resources finding appropriate content, tools for monitoring or limiting child use, ideas for play or activities in which to engage rather than digital play, and how parents can limit their own media use (see HealthyChildren.org for examples); each of these can be built into the Family Media Use Plan (see the American Academy of Pediatrics guide to developing a plan at www.healthychildren.org/MediaUsePlan).

Recommendations

Pediatricians

Start the conversation early. Ask parents of infants and young children about family media use, their children’s use habits, and media use locations.

Help families develop a Family Media Use Plan (www.healthychildren.org/MediaUsePlan) with specific guidelines for each child and parent.

Educate parents about brain development in the early years and the importance of hands-on, unstructured, and social play to build language, cognitive, and social-emotional skills.

For children younger than 18 months, discourage use of screen media other than video-chatting.

For parents of children 18 to 24 months of age who want to introduce digital media, advise that they choose high-quality programming/apps and use them together with children, because this is how toddlers learn best. Letting children use media by themselves should be avoided.

In children older than 2 years, limit media to 1 hour or less per day of high-quality programming. Recommend shared use between parent and child to promote enhanced learning, greater interaction, and limit setting.

Avoid digital media use (except video-chatting) in children younger than 18 to 24 months.

For children ages 18 to 24 months of age, if you want to introduce digital media, choose high-quality programming and use media together with your child. Avoid solo media use in this age group.

Do not feel pressured to introduce technology early; interfaces are so intuitive that children will figure them out quickly once they start using them at home or in school.

For children 2 to 5 years of age, limit screen use to 1 hour per day of high-quality programming, coview with your children, help children understand what they are seeing, and help them apply what they learn to the world around them.

Avoid fast-paced programs (young children do not understand them as well), apps with lots of distracting content, and any violent content.

Turn off televisions and other devices when not in use.

Avoid using media as the only way to calm your child. Although there are intermittent times (eg, medical procedures, airplane flights) when media is useful as a soothing strategy, there is concern that using media as strategy to calm could lead to problems with limit setting or the inability of children to develop their own emotion regulation. Ask your pediatrician for help if needed.

Monitor children’s media content and what apps are used or downloaded. Test apps before the child uses them, play together, and ask the child what he or she thinks about the app.

Keep bedrooms, mealtimes, and parent–child playtimes screen free for children and parents. Parents can set a “do not disturb” option on their phones during these times.

No screens 1 hour before bedtime, and remove devices from bedrooms before bed.

Consult the American Academy of Pediatrics Family Media Use Plan, available at: www.healthychildren.org/MediaUsePlan.

Industry

Work with developmental psychologists and educators to create design interfaces that are appropriate to child developmental abilities, that are not distracting, and that promote shared parent–child media use and application of skills to the real world. Cease making apps for children younger than 18 months until evidence of benefit is demonstrated.

Formally and scientifically evaluate products before making educational claims.

Make high-quality products accessible and affordable to low-income families and in multiple languages.

Eliminate advertising and unhealthy messages on apps. Children at this age cannot differentiate between advertisements and factual information, and therefore, advertising to them is unethical.

Help parents to set limits by stopping auto-advance of videos as the default setting. Develop systems embedded in devices that can help parents monitor and limit media use.

Researchers are calling for a nationwide ban on crib bumpers after finding they are linked to a growing number of infant deaths.

Twenty-three deaths related to crib bumpers were reported to the U.S. Consumer Product Safety Commission (CPSC) from 2006 through 2012, according to the report “Crib Bumpers Continue to Cause Infant Deaths: A Need for a New Preventive Approach.” Eight deaths were reported in each of the three previous seven-year periods.

“Crib bumpers are killing kids,” senior author Bradley T. Thach, M.D., professor emeritus of pediatrics at the Washington University School of Medicine, said in a news release. “Bumpers are more dangerous than we originally thought. The infant deaths we studied could have been prevented if the cribs were empty.”

There were 48 deaths related to crib bumpers from 1985 through 2012, most due to suffocation, according to a review of CPSC data detailed in the report (Scheers NJ, et al. J Pediatr. Nov. 24, 2015, www.sciencedirect.com/science/article/pii/S0022347615012846). In an additional 146 incidents, babies nearly suffocated or choked.

Researchers acknowledged the increase over previous years could be due in part to better reporting to CPSC but also said they believe the actual figures may be higher as they found additional bumper-related deaths when reviewing data from the National Center for the Review and Prevention of Child Deaths.

The Academy, the National Institutes of Health and the Centers for Disease Control and Prevention all recommend against bumpers, but there are no federal regulations regarding their use. Researchers, two of whom previously worked for the CPSC, said that agency would be responsible for instituting a ban, but it has limited resources.

“A ban on crib bumpers would reinforce the message that no soft bedding of any kind should be placed inside a baby's crib,” Dr. Thach said. "There is one sure-fire way to prevent infant deaths from crib bumpers: Don't use them, ever."

Researchers are calling for a nationwide ban on crib bumpers after finding they are linked to a growing number of infant deaths.

Twenty-three deaths related to crib bumpers were reported to the U.S. Consumer Product Safety Commission (CPSC) from 2006 through 2012, according to the report “Crib Bumpers Continue to Cause Infant Deaths: A Need for a New Preventive Approach.” Eight deaths were reported in each of the three previous seven-year periods.

“Crib bumpers are killing kids,” senior author Bradley T. Thach, M.D., professor emeritus of pediatrics at the Washington University School of Medicine, said in a news release. “Bumpers are more dangerous than we originally thought. The infant deaths we studied could have been prevented if the cribs were empty.”

There were 48 deaths related to crib bumpers from 1985 through 2012, most due to suffocation, according to a review of CPSC data detailed in the report (Scheers NJ, et al. J Pediatr. Nov. 24, 2015, www.sciencedirect.com/science/article/pii/S0022347615012846). In an additional 146 incidents, babies nearly suffocated or choked.

Researchers acknowledged the increase over previous years could be due in part to better reporting to CPSC but also said they believe the actual figures may be higher as they found additional bumper-related deaths when reviewing data from the National Center for the Review and Prevention of Child Deaths.

The Academy, the National Institutes of Health and the Centers for Disease Control and Prevention all recommend against bumpers, but there are no federal regulations regarding their use. Researchers, two of whom previously worked for the CPSC, said that agency would be responsible for instituting a ban, but it has limited resources.

“A ban on crib bumpers would reinforce the message that no soft bedding of any kind should be placed inside a baby's crib,” Dr. Thach said. "There is one sure-fire way to prevent infant deaths from crib bumpers: Don't use them, ever."

Major achievements in pediatric research, often taken for granted, have been made possible with federal funding. A recent congressional briefing hosted by the AAP Committee on Pediatric Research highlighted discoveries from the last 40 years from the perspectives of researchers and families.
From passenger safety laws to the use of surfactant to rotavirus vaccines, pediatric research innovations over the last four decades have led to life-saving discoveries and policy changes that many take for granted.

Despite the importance of these advancements, researchers don’t always do a good job explaining the impact of their work and how it saves lives, said Tina Cheng, M.D., M.P.H., FAAP, chair of the AAP Committee on Pediatric Research (COPR).

That’s one reason the committee hosted a congressional briefing in December to present to lawmakers “7 Great Achievements in Pediatric Research” (see sidebar). Researchers and family members impacted by the research spoke to a standing-room-only crowd, focusing on innovations in the members’ lifetimes.

The topics covered immunizations, pediatric cancer, saving premature infants, preventing HIV transmission from mothers to babies, reducing sudden infant death syndrome (SIDS), increasing life expectancy for children with chronic diseases, and saving lives with car seats and seat belts. Forty years ago some of these discoveries may have seemed like science fiction.

To help select the topics, COPR surveyed its members along with the boards of the American Pediatric Society, Academic Pediatric Association, Society for Pediatric Research, Federation of Pediatric Organizations and Association of Medical School Pediatric Department Chairs. The groups, along with the Academy, sponsored the briefing.

“We chose the seven because we felt like they were recent successes and they were successes that would resonate with the public,” said Dr. Cheng, who moderated the briefing.

SPEAKING FROM THE HEART

Researchers shared their perspectives, but when family members and young people offered their stories about how research changed their lives, it was even more powerful, said neonatologist Scott Denne, M.D., FAAP, past chair of COPR.

Tokunbo Olaniyan, of Columbia, Md., a young woman whose late mother had sickle cell disease, talked about how grateful she was that her mother lived to be old enough to give birth. Forty years ago, sickle cell patients in the United States typically lived to only about 14 years.

College student Vikram Siberry, of Olney, Md., told how a seatbelt saved him during a car accident in high school that took the life of his friend who was behind the wheel.

Dr. Denne also shared how the introduction of surfactant to treat premature babies has affected his professional life.

“The difference is as night-and-day as any intervention has ever been,” he said.

“Before surfactant, our primary tools were the ventilator, and premature babies were born and immediately struggled to breathe,” he told the group. “The ventilator caused substantial damage — major ruptures of the lung — so you had to put in chest tubes. Babies needed to stay on ventilators for prolonged periods. Many babies who left the nursery had significant lung disease, and many babies simply didn’t survive.

“A daily event was babies dying … multiple chest tubes being placed … a whole host of rooms dedicated for babies who were going to be on ventilators for months. That was the reality before surfactant,” Dr. Denne said.

Today, many babies come off ventilators more quickly, lung damage is significantly less severe and survival rates have increased substantially, he noted.

SIDS was addressed by Marian Willinger, Ph.D., director of the research program in SIDS at the Eunice Kennedy Shriver National Institute for Child Health and Human Development. Dr. Willinger, consultant to the AAP Task Force on SIDS, coordinated much of the research efforts on the Back to Sleep campaign. Since 1994, the overall U.S. SIDS rate has declined by more than half as a result of babies being placed on their backs to sleep.

The briefing included graphs and charts on topics such as the progress made in life expectancy for patients with sickle cell anemia and cystic fibrosis. One chart showed the steep drop in perinatally acquired AIDS in the early 1990s with the introduction of an antiretroviral medication.

IMPORTANCE OF FUNDING

All of the stories were designed to help lawmakers and others understand the ongoing need for federal research funding.

“It’s very important for the general public to understand how impactful investing in research can and has been,” said Dr. Denne, who said funding should be maintained or better yet, increased.

Although the seven achievements will be no surprise to any pediatrician, Dr. Cheng said they all are taken for granted sometimes and continued investment is needed.

“All of these discoveries were the result of research funding innovation that led to decreased mortality, increased life expectancy, increased quality of life. There are more research discoveries to be made.”

7 Great Achievements in Pediatric Research in the Past 40 Years

Preventing disease with life-saving immunizations

Diseases like rotavirus and Haemophilus influenzae type b are now preventable due to vaccines.

Saving premature babies by helping them breathe

Deaths from respiratory distress syndrome have been reduced by two-thirds with the introduction of surfactant.

Reducing sudden infant death syndrome (SIDS) with Back to Sleep

SIDS has declined by half due to research and the Back to Sleep campaign.

Curing a common childhood cancer

More than 90% of children with acute lymphocytic leukemia now survive, compared with 57% in the 1970s.

Major achievements in pediatric research, often taken for granted, have been made possible with federal funding. A recent congressional briefing hosted by the AAP Committee on Pediatric Research highlighted discoveries from the last 40 years from the perspectives of researchers and families.
From passenger safety laws to the use of surfactant to rotavirus vaccines, pediatric research innovations over the last four decades have led to life-saving discoveries and policy changes that many take for granted.

Despite the importance of these advancements, researchers don’t always do a good job explaining the impact of their work and how it saves lives, said Tina Cheng, M.D., M.P.H., FAAP, chair of the AAP Committee on Pediatric Research (COPR).

That’s one reason the committee hosted a congressional briefing in December to present to lawmakers “7 Great Achievements in Pediatric Research” (see sidebar). Researchers and family members impacted by the research spoke to a standing-room-only crowd, focusing on innovations in the members’ lifetimes.

The topics covered immunizations, pediatric cancer, saving premature infants, preventing HIV transmission from mothers to babies, reducing sudden infant death syndrome (SIDS), increasing life expectancy for children with chronic diseases, and saving lives with car seats and seat belts. Forty years ago some of these discoveries may have seemed like science fiction.

To help select the topics, COPR surveyed its members along with the boards of the American Pediatric Society, Academic Pediatric Association, Society for Pediatric Research, Federation of Pediatric Organizations and Association of Medical School Pediatric Department Chairs. The groups, along with the Academy, sponsored the briefing.

“We chose the seven because we felt like they were recent successes and they were successes that would resonate with the public,” said Dr. Cheng, who moderated the briefing.

SPEAKING FROM THE HEART

Researchers shared their perspectives, but when family members and young people offered their stories about how research changed their lives, it was even more powerful, said neonatologist Scott Denne, M.D., FAAP, past chair of COPR.

Tokunbo Olaniyan, of Columbia, Md., a young woman whose late mother had sickle cell disease, talked about how grateful she was that her mother lived to be old enough to give birth. Forty years ago, sickle cell patients in the United States typically lived to only about 14 years.

College student Vikram Siberry, of Olney, Md., told how a seatbelt saved him during a car accident in high school that took the life of his friend who was behind the wheel.

Dr. Denne also shared how the introduction of surfactant to treat premature babies has affected his professional life.

“The difference is as night-and-day as any intervention has ever been,” he said.

“Before surfactant, our primary tools were the ventilator, and premature babies were born and immediately struggled to breathe,” he told the group. “The ventilator caused substantial damage — major ruptures of the lung — so you had to put in chest tubes. Babies needed to stay on ventilators for prolonged periods. Many babies who left the nursery had significant lung disease, and many babies simply didn’t survive.

“A daily event was babies dying … multiple chest tubes being placed … a whole host of rooms dedicated for babies who were going to be on ventilators for months. That was the reality before surfactant,” Dr. Denne said.

Today, many babies come off ventilators more quickly, lung damage is significantly less severe and survival rates have increased substantially, he noted.

SIDS was addressed by Marian Willinger, Ph.D., director of the research program in SIDS at the Eunice Kennedy Shriver National Institute for Child Health and Human Development. Dr. Willinger, consultant to the AAP Task Force on SIDS, coordinated much of the research efforts on the Back to Sleep campaign. Since 1994, the overall U.S. SIDS rate has declined by more than half as a result of babies being placed on their backs to sleep.

The briefing included graphs and charts on topics such as the progress made in life expectancy for patients with sickle cell anemia and cystic fibrosis. One chart showed the steep drop in perinatally acquired AIDS in the early 1990s with the introduction of an antiretroviral medication.

IMPORTANCE OF FUNDING

All of the stories were designed to help lawmakers and others understand the ongoing need for federal research funding.

“It’s very important for the general public to understand how impactful investing in research can and has been,” said Dr. Denne, who said funding should be maintained or better yet, increased.

Although the seven achievements will be no surprise to any pediatrician, Dr. Cheng said they all are taken for granted sometimes and continued investment is needed.

“All of these discoveries were the result of research funding innovation that led to decreased mortality, increased life expectancy, increased quality of life. There are more research discoveries to be made.”

7 Great Achievements in Pediatric Research in the Past 40 Years

Preventing disease with life-saving immunizations

Diseases like rotavirus and Haemophilus influenzae type b are now preventable due to vaccines.

Saving premature babies by helping them breathe

Deaths from respiratory distress syndrome have been reduced by two-thirds with the introduction of surfactant.

Reducing sudden infant death syndrome (SIDS) with Back to Sleep

SIDS has declined by half due to research and the Back to Sleep campaign.

Curing a common childhood cancer

More than 90% of children with acute lymphocytic leukemia now survive, compared with 57% in the 1970s.

2013年，AAP和美国家庭医师学会(American Academy of Family Physicians)发布了更新后的AOM诊断和治疗临床实践指南。22AOM的定义为：“中耳炎症状和体征的快速发作。”上述体征包括伴有或不伴有红斑的鼓膜(TM)膨出，症状可能包括耳痛、烦躁、耳漏和发热等。诊断AOM往往需要仔细的耳镜检查，以确认存在TM炎性改变。AAP指南建议，在以下任何一种情况下医生都可以确诊AOM：(1)有证据表明存在中耳积液（TM中度到重度膨出）；或(2)不能归因于外耳道炎的新发耳漏。如果患儿仅出现轻度TM膨出，但伴有最近发生的耳部疼痛或TM严重红斑，也可以确诊AOM。由于清晰地观察TM可能有困难，且AOM通常是自限性疾病，为了尽量减少抗生素滥用，必须确保诊断的高度准确性。在确诊AOM后，根据疾病的严重程度（严重耳痛，耳痛持续>48小时，或体温≥39°C）、感染的偏侧性（双侧与单侧）、以及年龄（≤23个月和≥24个月）对患者进行分类将有助于合理地使用抗生素。症状严重、双侧受累且年龄较小的患者更可能受益于抗生素。对于年龄稍大、病情不严重且为单侧发病的患者，随访观察是较为合理的处置。

2013年，AAP和美国家庭医师学会(American Academy of Family Physicians)发布了更新后的AOM诊断和治疗临床实践指南。22AOM的定义为：“中耳炎症状和体征的快速发作。”上述体征包括伴有或不伴有红斑的鼓膜(TM)膨出，症状可能包括耳痛、烦躁、耳漏和发热等。诊断AOM往往需要仔细的耳镜检查，以确认存在TM炎性改变。AAP指南建议，在以下任何一种情况下医生都可以确诊AOM：(1)有证据表明存在中耳积液（TM中度到重度膨出）；或(2)不能归因于外耳道炎的新发耳漏。如果患儿仅出现轻度TM膨出，但伴有最近发生的耳部疼痛或TM严重红斑，也可以确诊AOM。由于清晰地观察TM可能有困难，且AOM通常是自限性疾病，为了尽量减少抗生素滥用，必须确保诊断的高度准确性。在确诊AOM后，根据疾病的严重程度（严重耳痛，耳痛持续>48小时，或体温≥39°C）、感染的偏侧性（双侧与单侧）、以及年龄（≤23个月和≥24个月）对患者进行分类将有助于合理地使用抗生素。症状严重、双侧受累且年龄较小的患者更可能受益于抗生素。对于年龄稍大、病情不严重且为单侧发病的患者，随访观察是较为合理的处置。

Abstract
Oral health is an integral part of the overall health of children. Dental caries is a common and chronic disease process with significant short- and long-term consequences. The prevalence of dental caries for the youngest of children has not decreased over the past decade, despite improvements for older children. As health care professionals responsible for the overall health of children, pediatricians frequently confront morbidity associated with dental caries. Because the youngest children visit the pediatrician more often than they visit the dentist, it is important that pediatricians be knowledgeable about the disease process of dental caries, prevention of the disease, and interventions available to the pediatrician and the family to maintain and restore health.

Introduction
Dental caries is the most common chronic disease of childhood. Twenty-four percent of US children 2 to 4 years of age, 53% of children 6 to 8 years of age, and 56% of 15-year-olds have caries experience (ie, untreated dental caries, filled teeth, teeth missing as a result of dental caries). For children 5 to 19 years of age, children from poor and racial or ethnic minority families have higher rates of untreated dental caries than do their peers from nonpoor and nonminority families. For some age groups, the incidence of dental caries has decreased or stayed the same, but for the youngest children, it has increased. Among 6- to 8-year-olds and 15-year-olds, caries experience and untreated dental decay remained mostly unchanged between 1988–1994 and 1999–2004. In children 2 to 4 years of age, the caries experience increased significantly, from 19% to 24%, during that same time period. The increase in the caries experience and untreated caries was statistically significant in children from poor families.

The Etiology and Pathogenesis of Dental Caries
A dynamic process takes place at the surface of the tooth that involves constant demineralization and remineralization of the tooth enamel (the caries balance). Multiple factors affect that dynamic process and can be manipulated in ways that tip the balance toward disease (demineralization) or health (remineralization). These factors include bacteria, sugar, saliva, and fluoride. Because these factors can be manipulated, it is possible for pediatricians and families to prevent, halt, or even reverse the disease process.

Different oral structures and tissues have different and distinct microbial communities (microbiomes). The oral microbiome at the surface of the tooth is referred to as dental plaque. During the disease process of dental caries, bacteria that are aciduric and acidogenic predominate in the dental plaque. Streptococcus mutans is most strongly associated with dental caries, although other bacterial species have these capabilities and thus can also be pathogenic. When environmental factors make it possible to select for these pathogenic bacteria in dental plaque, the disease process begins.

A key environmental factor that allows for selection and proliferation of these pathogenic bacteria is dietary sugar intake. Because these pathogenic bacteria have the ability to ferment sugars, produce acid, and decrease the pH of the dental plaque, they make possible the selection of other aciduric, acidogenic bacteria that will contribute to disease. As more bacteria produce more acid, the pH at the surface of the tooth decreases. This process causes the demineralization of the tooth enamel. Unimpeded, these long periods of low pH and demineralization will result in cavitation.

Saliva is an important factor in buffering the low pH and bringing these demineralization pressures back to a balance with remineralization. In addition to acting as a buffering agent, saliva also flushes the oral cavity of food particles and provides an environment rich in calcium and phosphate to aid in remineralization. When salivary flow is impeded, the pH is able to decrease to a lower level, tipping the scales toward demineralization (disease); in addition, the time it takes to buffer back to a normal pH is longer.

Another important factor that can affect the balance of demineralization and remineralization is fluoride. More in-depth reviews of fluoride are available elsewhere. It is important, however, for pediatricians and other child health care providers to understand how fluoride influences the caries balance. Fluoride has 3 key effects on the caries balance: (1) inhibition of demineralization at the tooth surface; (2) enhancement of remineralization, which results in a more acid-resistant tooth surface; and (3) inhibition of bacterial enzymes. The primary effect of fluoride is topical, via fluoridated toothpastes, mouth rinses, and varnishes, although there is still value in systemic fluoride exposures via fluoridated water and supplements.

Preventive Strategies

Caries Risk Assessment

Ideally, primary prevention efforts will anticipate and prevent caries before the first sign of disease. Preventive strategies for this multifactorial, chronic disease require a comprehensive and multifocal approach that begins with caries risk assessment. Assessing each child’s risk of caries and tailoring preventive strategies to specific risk factors are necessary for maintaining and improving oral health. There is no single test that takes into consideration all risk factors and accurately predicts an individual's susceptibility to caries. However, pediatricians can conduct an excellent risk assessment for caries by focusing on the key risk factors for dental caries that are associated with diet, bacteria, saliva, and status of the teeth (both current status and previous caries experience). The American Academy of Pediatrics (AAP)/Bright Futures Oral Health Risk Assessment Tool can be found at http://www2.aap.org/oralhealth ... html.

Sugars (but not sugar substitutes) are a critical risk factor in the development of caries. The risk of caries is greatest if sugars are consumed at high frequency and are in a form that remains in the mouth for long periods of time. Thus, key behaviors that place a child at high risk of caries include continual bottle/sippy cup use (especially with fluids other than water), sleeping with a bottle (especially with fluids other than water), frequent between-meal snacks of sugars/cooked starch/sugared beverages, and frequent intake of sugared medications.

Early acquisition of S mutans is a major risk factor for early childhood caries and future caries experience. Strong evidence demonstrates that mothers are a primary source of S mutans colonization for their children. Thus, an important factor associated with caries risk in young children is the recent or current presence of active dental decay in the primary caregiver. Prevention, diagnosis, and treatment of oral diseases are highly beneficial, can be undertaken, and should be encouraged during pregnancy with no additional fetal or maternal risk compared with the risk of not providing care. The most important and predictive risk factor for caries, however, is previous caries experience. This finding is not surprising, considering that the factors which initiated the disease process often continue to exist over time.

Other caries risk factors are associated with salivary flow and the status of the teeth. Diseases (eg, diabetes mellitus, Sjögren's syndrome, cystic fibrosis) and medications (eg, antihistamines, anticonvulsants, antidepressants) that result in xerostomia (decreased salivary flow) reduce the availability of saliva to buffer the acid produced by pathogenic bacteria, thus enhancing their ability to cause damage to the teeth. In addition, the teeth of preterm infants, which frequently have enamel defects, are at increased susceptibility for disease. Older children who have deep pits and fissures in their molars are also at increased susceptibility for disease.

Anticipatory Guidance
With a clear understanding of the etiology of dental caries and the risk factors that lead to and facilitate the spread of this disease, pediatricians can target anticipatory guidance to assist families in preventing it. Because the disease of dental caries is multifocal, the anticipatory guidance should also be multifocal. Pediatricians should concentrate their anticipatory guidance on topics that can affect the risk of disease.

Dietary Counseling
Because sugar intake is such an important risk factor for dental caries, pediatricians can incorporate anticipatory guidance associated with preventing dental caries into discussions with families about dietary habits and nutritional intake. Pediatricians should counsel parents and caregivers on the importance of reducing the frequency of exposure to sugars in foods and drinks. To decrease the risk of dental caries and ensure the best possible health and developmental outcomes, pediatricians should recommend that parents do the following:

•Exclusively breastfeed infants for 6 months and continue breastfeeding as complementary foods are introduced for 1 year or longer, as mutually desired by mother and infant.

•Discourage putting a child to bed with a bottle. Establish a bedtime routine conducive to optimal oral health (eg, brush, book, and bed).

•Wean from a bottle by 1 year of age.

•Limit sugary foods and drinks to mealtimes.

•Avoid carbonated, sugared beverages and juice drinks that are not 100% juice.

•Limit the intake of 100% fruit juice to no more than 4 to 6 oz per day.

•Encourage children to drink only water between meals, preferably fluoridated tap water.

•Foster eating patterns that are consistent with guidelines from the US Department of Agriculture.

Oral Hygiene
The value of good oral hygiene lies in controlling the levels and activity of disease-causing bacteria in the oral cavity and delivering fluoride to the surface of the tooth. It is important to remember that pathogenic bacteria can be passed from caregiver to child. Thus, anticipatory guidance for both parent and child is important. Key anticipatory guidance points regarding oral hygiene are as follows:

•Parents/caregivers should be encouraged to model and maintain good oral hygiene and a relationship with their own dental provider.

•Parents/caregivers, especially those with significant history of dental decay, should be cautioned to avoid sharing with their child items that have been in their own mouths.

•The child’s teeth should be brushed twice a day as soon as the teeth erupt with a smear or a grain-of-rice–sized amount of fluoridated toothpaste. After the third birthday, a pea-sized amount should be used.

•Parents/caregivers should help/supervise a child brushing his or her teeth until mastery is obtained, usually at around 8 years of age.

Fluoride
The delivery of fluoride to the teeth includes community-based options (water fluoridation), self-administered modalities (fluoride toothpaste and supplements), and professional applications (fluoride varnish). Each of these delivery mechanisms is useful in preventing dental caries.

Water fluoridation is a community-based intervention that optimizes the level of fluoride in drinking water, resulting in preeruptive and posteruptive protection of the teeth.19 Water fluoridation is a cost-effective means of preventing dental caries, with the lifetime cost per person equaling less than the cost of 1 dental restoration. Most bottled waters do not contain an adequate amount of fluoride.

Fluoride toothpaste is an important way to deliver fluoride to the surface of the tooth. Fluoride toothpaste has been shown to be effective in reducing dental caries in both primary and permanent teeth. It is important to limit the amount of toothpaste used to a smear or a grain-of-rice–sized amount for young children and no more than a pea-sized amount for children older than 3 years. Fluoride supplements should be prescribed for children whose primary source of drinking water is deficient in fluoride.

Fluoride varnish is a professionally applied, sticky resin of highly concentrated fluoride. Two or more applications of fluoride varnish per year are effective in preventing caries in children at high risk of all ages. In most states, pediatricians can apply and be paid for application of fluoride varnish to the teeth of young children. Application of fluoride varnish is even more effective when coupled with counseling. The US Preventive Services Task Force recently published a new recommendation that primary care clinicians apply fluoride varnish to the primary teeth of all infants and children starting at the age of primary tooth eruption (B recommendation). More details and recommendations on fluoride can be found in the AAP clinical report “Fluoride Use in Caries Prevention in the Primary Care Setting.”

Other Important Anticipatory Guidance Topics
A frequent topic of discussion with parents is nonnutritive oral habits, such as use of pacifiers and thumb sucking. AAP policy states that parents consider offering a pacifier at naptime and bedtime because of a protective effect of pacifiers on the incidence of sudden infant death syndrome after the first month of life.27 Both finger- and pacifier-sucking habits will only cause problems with dental structures if they go on for a long period of time. Evaluation by a dentist is indicated for nonnutritive sucking habits that continue beyond 3 years of age.28

Dental injuries are common. Twenty-five percent of all schoolchildren experience some form of dental trauma. Pediatricians can help prevent such trauma by encouraging parents to cover sharp corners of household furnishings at the level of walking toddlers, recommend use of car safety seats, and be aware of electrical cord risk for mouth injury. Pediatricians can also encourage mouthguard use during sports activities in which there is a significant risk of orofacial injury.More information on dental trauma is available in the AAP clinical report “Management of Dental Trauma in a Primary Care Setting.”

Collaboration With Dental Providers
The AAP, the American Academy of Pediatric Dentistry, the American Dental Association, and the American Association of Public Health Dentistry all recommend a dental visit for children by 1 year of age. Although pediatricians have the opportunity to provide early assessment of risk for dental caries and anticipatory guidance to prevent disease, it is also important that children establish a dental home. A dental home is the ongoing relationship between the dentist and the patient, inclusive of all aspects of oral health care delivered in a comprehensive, continuously accessible, coordinated, and family-centered way.

Unfortunately, little is known about pediatric health care providers’ dental referral behaviors and patterns. Although 1 study found that children 2 to 5 years of age who received a recommendation from their health care provider to visit the dentist were more likely to have a dental visit, the US Preventive Services Task Force found no study that evaluated the effects of referral by a primary care clinician to a dentist on caries incidence. It is also noteworthy that preschool-aged children covered by Medicaid who had an early preventive dental visit by 1 year of age were more likely to use subsequent preventive services and to have lower dental expenses.

With early referral to a dental provider, there is an opportunity to maintain good oral health, prevent disease, and treat disease early. Establishing such collaborative relationships between physicians and dentists at the community level is essential for increasing access to dental care for all children and improving their oral and overall health.

Conclusions
Oral health is an integral part of the overall health and well-being of children. A pediatrician who is familiar with the science of dental caries, capable of assessing caries risk, comfortable with applying various strategies of prevention and intervention, and connected to dental resources can contribute considerably to the health of his or her patients. This policy statement, in conjunction with the oral health recommendations of the third edition of the AAP's Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, serves as a resource for pediatricians and other pediatric primary care providers to be knowledgeable about addressing dental caries. Because dental caries is such a common and consequential disease process in the pediatric population, it is essential that pediatricians include oral health in their daily practice of pediatrics.

Suggestions for Pediatricians

1.Administer an oral health risk assessment periodically to all children.

2.Include anticipatory guidance for oral health as an integral part of comprehensive patient counseling.

3.Counsel parents/caregivers and patients to reduce the frequency of exposure to sugars in foods and drinks.

4.Encourage parents/caregivers to brush a child’s teeth as soon as teeth erupt with a smear or a grain-of-rice–sized amount of fluoride toothpaste and a pea-sized amount at 3 years of age.

5.Advise parents/caregivers to monitor brushing until 8 years of age.

6.Refer to the AAP clinical report, “Fluoride Use in Caries Prevention in the Primary Care Setting,” for fluoride administration and supplementation decisions.

Abstract
Oral health is an integral part of the overall health of children. Dental caries is a common and chronic disease process with significant short- and long-term consequences. The prevalence of dental caries for the youngest of children has not decreased over the past decade, despite improvements for older children. As health care professionals responsible for the overall health of children, pediatricians frequently confront morbidity associated with dental caries. Because the youngest children visit the pediatrician more often than they visit the dentist, it is important that pediatricians be knowledgeable about the disease process of dental caries, prevention of the disease, and interventions available to the pediatrician and the family to maintain and restore health.

Introduction
Dental caries is the most common chronic disease of childhood. Twenty-four percent of US children 2 to 4 years of age, 53% of children 6 to 8 years of age, and 56% of 15-year-olds have caries experience (ie, untreated dental caries, filled teeth, teeth missing as a result of dental caries). For children 5 to 19 years of age, children from poor and racial or ethnic minority families have higher rates of untreated dental caries than do their peers from nonpoor and nonminority families. For some age groups, the incidence of dental caries has decreased or stayed the same, but for the youngest children, it has increased. Among 6- to 8-year-olds and 15-year-olds, caries experience and untreated dental decay remained mostly unchanged between 1988–1994 and 1999–2004. In children 2 to 4 years of age, the caries experience increased significantly, from 19% to 24%, during that same time period. The increase in the caries experience and untreated caries was statistically significant in children from poor families.

The Etiology and Pathogenesis of Dental Caries
A dynamic process takes place at the surface of the tooth that involves constant demineralization and remineralization of the tooth enamel (the caries balance). Multiple factors affect that dynamic process and can be manipulated in ways that tip the balance toward disease (demineralization) or health (remineralization). These factors include bacteria, sugar, saliva, and fluoride. Because these factors can be manipulated, it is possible for pediatricians and families to prevent, halt, or even reverse the disease process.

Different oral structures and tissues have different and distinct microbial communities (microbiomes). The oral microbiome at the surface of the tooth is referred to as dental plaque. During the disease process of dental caries, bacteria that are aciduric and acidogenic predominate in the dental plaque. Streptococcus mutans is most strongly associated with dental caries, although other bacterial species have these capabilities and thus can also be pathogenic. When environmental factors make it possible to select for these pathogenic bacteria in dental plaque, the disease process begins.

A key environmental factor that allows for selection and proliferation of these pathogenic bacteria is dietary sugar intake. Because these pathogenic bacteria have the ability to ferment sugars, produce acid, and decrease the pH of the dental plaque, they make possible the selection of other aciduric, acidogenic bacteria that will contribute to disease. As more bacteria produce more acid, the pH at the surface of the tooth decreases. This process causes the demineralization of the tooth enamel. Unimpeded, these long periods of low pH and demineralization will result in cavitation.

Saliva is an important factor in buffering the low pH and bringing these demineralization pressures back to a balance with remineralization. In addition to acting as a buffering agent, saliva also flushes the oral cavity of food particles and provides an environment rich in calcium and phosphate to aid in remineralization. When salivary flow is impeded, the pH is able to decrease to a lower level, tipping the scales toward demineralization (disease); in addition, the time it takes to buffer back to a normal pH is longer.

Another important factor that can affect the balance of demineralization and remineralization is fluoride. More in-depth reviews of fluoride are available elsewhere. It is important, however, for pediatricians and other child health care providers to understand how fluoride influences the caries balance. Fluoride has 3 key effects on the caries balance: (1) inhibition of demineralization at the tooth surface; (2) enhancement of remineralization, which results in a more acid-resistant tooth surface; and (3) inhibition of bacterial enzymes. The primary effect of fluoride is topical, via fluoridated toothpastes, mouth rinses, and varnishes, although there is still value in systemic fluoride exposures via fluoridated water and supplements.

Preventive Strategies

Caries Risk Assessment

Ideally, primary prevention efforts will anticipate and prevent caries before the first sign of disease. Preventive strategies for this multifactorial, chronic disease require a comprehensive and multifocal approach that begins with caries risk assessment. Assessing each child’s risk of caries and tailoring preventive strategies to specific risk factors are necessary for maintaining and improving oral health. There is no single test that takes into consideration all risk factors and accurately predicts an individual's susceptibility to caries. However, pediatricians can conduct an excellent risk assessment for caries by focusing on the key risk factors for dental caries that are associated with diet, bacteria, saliva, and status of the teeth (both current status and previous caries experience). The American Academy of Pediatrics (AAP)/Bright Futures Oral Health Risk Assessment Tool can be found at http://www2.aap.org/oralhealth ... html.

Sugars (but not sugar substitutes) are a critical risk factor in the development of caries. The risk of caries is greatest if sugars are consumed at high frequency and are in a form that remains in the mouth for long periods of time. Thus, key behaviors that place a child at high risk of caries include continual bottle/sippy cup use (especially with fluids other than water), sleeping with a bottle (especially with fluids other than water), frequent between-meal snacks of sugars/cooked starch/sugared beverages, and frequent intake of sugared medications.

Early acquisition of S mutans is a major risk factor for early childhood caries and future caries experience. Strong evidence demonstrates that mothers are a primary source of S mutans colonization for their children. Thus, an important factor associated with caries risk in young children is the recent or current presence of active dental decay in the primary caregiver. Prevention, diagnosis, and treatment of oral diseases are highly beneficial, can be undertaken, and should be encouraged during pregnancy with no additional fetal or maternal risk compared with the risk of not providing care. The most important and predictive risk factor for caries, however, is previous caries experience. This finding is not surprising, considering that the factors which initiated the disease process often continue to exist over time.

Other caries risk factors are associated with salivary flow and the status of the teeth. Diseases (eg, diabetes mellitus, Sjögren's syndrome, cystic fibrosis) and medications (eg, antihistamines, anticonvulsants, antidepressants) that result in xerostomia (decreased salivary flow) reduce the availability of saliva to buffer the acid produced by pathogenic bacteria, thus enhancing their ability to cause damage to the teeth. In addition, the teeth of preterm infants, which frequently have enamel defects, are at increased susceptibility for disease. Older children who have deep pits and fissures in their molars are also at increased susceptibility for disease.

Anticipatory Guidance
With a clear understanding of the etiology of dental caries and the risk factors that lead to and facilitate the spread of this disease, pediatricians can target anticipatory guidance to assist families in preventing it. Because the disease of dental caries is multifocal, the anticipatory guidance should also be multifocal. Pediatricians should concentrate their anticipatory guidance on topics that can affect the risk of disease.

Dietary Counseling
Because sugar intake is such an important risk factor for dental caries, pediatricians can incorporate anticipatory guidance associated with preventing dental caries into discussions with families about dietary habits and nutritional intake. Pediatricians should counsel parents and caregivers on the importance of reducing the frequency of exposure to sugars in foods and drinks. To decrease the risk of dental caries and ensure the best possible health and developmental outcomes, pediatricians should recommend that parents do the following:

•Exclusively breastfeed infants for 6 months and continue breastfeeding as complementary foods are introduced for 1 year or longer, as mutually desired by mother and infant.

•Discourage putting a child to bed with a bottle. Establish a bedtime routine conducive to optimal oral health (eg, brush, book, and bed).

•Wean from a bottle by 1 year of age.

•Limit sugary foods and drinks to mealtimes.

•Avoid carbonated, sugared beverages and juice drinks that are not 100% juice.

•Limit the intake of 100% fruit juice to no more than 4 to 6 oz per day.

•Encourage children to drink only water between meals, preferably fluoridated tap water.

•Foster eating patterns that are consistent with guidelines from the US Department of Agriculture.

Oral Hygiene
The value of good oral hygiene lies in controlling the levels and activity of disease-causing bacteria in the oral cavity and delivering fluoride to the surface of the tooth. It is important to remember that pathogenic bacteria can be passed from caregiver to child. Thus, anticipatory guidance for both parent and child is important. Key anticipatory guidance points regarding oral hygiene are as follows:

•Parents/caregivers should be encouraged to model and maintain good oral hygiene and a relationship with their own dental provider.

•Parents/caregivers, especially those with significant history of dental decay, should be cautioned to avoid sharing with their child items that have been in their own mouths.

•The child’s teeth should be brushed twice a day as soon as the teeth erupt with a smear or a grain-of-rice–sized amount of fluoridated toothpaste. After the third birthday, a pea-sized amount should be used.

•Parents/caregivers should help/supervise a child brushing his or her teeth until mastery is obtained, usually at around 8 years of age.

Fluoride
The delivery of fluoride to the teeth includes community-based options (water fluoridation), self-administered modalities (fluoride toothpaste and supplements), and professional applications (fluoride varnish). Each of these delivery mechanisms is useful in preventing dental caries.

Water fluoridation is a community-based intervention that optimizes the level of fluoride in drinking water, resulting in preeruptive and posteruptive protection of the teeth.19 Water fluoridation is a cost-effective means of preventing dental caries, with the lifetime cost per person equaling less than the cost of 1 dental restoration. Most bottled waters do not contain an adequate amount of fluoride.

Fluoride toothpaste is an important way to deliver fluoride to the surface of the tooth. Fluoride toothpaste has been shown to be effective in reducing dental caries in both primary and permanent teeth. It is important to limit the amount of toothpaste used to a smear or a grain-of-rice–sized amount for young children and no more than a pea-sized amount for children older than 3 years. Fluoride supplements should be prescribed for children whose primary source of drinking water is deficient in fluoride.

Fluoride varnish is a professionally applied, sticky resin of highly concentrated fluoride. Two or more applications of fluoride varnish per year are effective in preventing caries in children at high risk of all ages. In most states, pediatricians can apply and be paid for application of fluoride varnish to the teeth of young children. Application of fluoride varnish is even more effective when coupled with counseling. The US Preventive Services Task Force recently published a new recommendation that primary care clinicians apply fluoride varnish to the primary teeth of all infants and children starting at the age of primary tooth eruption (B recommendation). More details and recommendations on fluoride can be found in the AAP clinical report “Fluoride Use in Caries Prevention in the Primary Care Setting.”

Other Important Anticipatory Guidance Topics
A frequent topic of discussion with parents is nonnutritive oral habits, such as use of pacifiers and thumb sucking. AAP policy states that parents consider offering a pacifier at naptime and bedtime because of a protective effect of pacifiers on the incidence of sudden infant death syndrome after the first month of life.27 Both finger- and pacifier-sucking habits will only cause problems with dental structures if they go on for a long period of time. Evaluation by a dentist is indicated for nonnutritive sucking habits that continue beyond 3 years of age.28

Dental injuries are common. Twenty-five percent of all schoolchildren experience some form of dental trauma. Pediatricians can help prevent such trauma by encouraging parents to cover sharp corners of household furnishings at the level of walking toddlers, recommend use of car safety seats, and be aware of electrical cord risk for mouth injury. Pediatricians can also encourage mouthguard use during sports activities in which there is a significant risk of orofacial injury.More information on dental trauma is available in the AAP clinical report “Management of Dental Trauma in a Primary Care Setting.”

Collaboration With Dental Providers
The AAP, the American Academy of Pediatric Dentistry, the American Dental Association, and the American Association of Public Health Dentistry all recommend a dental visit for children by 1 year of age. Although pediatricians have the opportunity to provide early assessment of risk for dental caries and anticipatory guidance to prevent disease, it is also important that children establish a dental home. A dental home is the ongoing relationship between the dentist and the patient, inclusive of all aspects of oral health care delivered in a comprehensive, continuously accessible, coordinated, and family-centered way.

Unfortunately, little is known about pediatric health care providers’ dental referral behaviors and patterns. Although 1 study found that children 2 to 5 years of age who received a recommendation from their health care provider to visit the dentist were more likely to have a dental visit, the US Preventive Services Task Force found no study that evaluated the effects of referral by a primary care clinician to a dentist on caries incidence. It is also noteworthy that preschool-aged children covered by Medicaid who had an early preventive dental visit by 1 year of age were more likely to use subsequent preventive services and to have lower dental expenses.

With early referral to a dental provider, there is an opportunity to maintain good oral health, prevent disease, and treat disease early. Establishing such collaborative relationships between physicians and dentists at the community level is essential for increasing access to dental care for all children and improving their oral and overall health.

Conclusions
Oral health is an integral part of the overall health and well-being of children. A pediatrician who is familiar with the science of dental caries, capable of assessing caries risk, comfortable with applying various strategies of prevention and intervention, and connected to dental resources can contribute considerably to the health of his or her patients. This policy statement, in conjunction with the oral health recommendations of the third edition of the AAP's Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, serves as a resource for pediatricians and other pediatric primary care providers to be knowledgeable about addressing dental caries. Because dental caries is such a common and consequential disease process in the pediatric population, it is essential that pediatricians include oral health in their daily practice of pediatrics.

Suggestions for Pediatricians

1.Administer an oral health risk assessment periodically to all children.

2.Include anticipatory guidance for oral health as an integral part of comprehensive patient counseling.

3.Counsel parents/caregivers and patients to reduce the frequency of exposure to sugars in foods and drinks.

4.Encourage parents/caregivers to brush a child’s teeth as soon as teeth erupt with a smear or a grain-of-rice–sized amount of fluoride toothpaste and a pea-sized amount at 3 years of age.

5.Advise parents/caregivers to monitor brushing until 8 years of age.

6.Refer to the AAP clinical report, “Fluoride Use in Caries Prevention in the Primary Care Setting,” for fluoride administration and supplementation decisions.